Concussion in children and adolescents: Management

INTRODUCTION — This topic will discuss the management of concussion in children and adolescents. The clinical manifestations and diagnosis of concussion in children, the sideline evaluation of concussion, concussions and traumatic brain injury in adults, and postconcussion syndrome are discussed separately:

●(See "Concussion in children and adolescents: Clinical manifestations and diagnosis".)

●(See "Sideline evaluation of concussion".)

●(See "Acute mild traumatic brain injury (concussion) in adults".)

●(See "Postconcussion syndrome".)

INITIAL APPROACH — Some concussions are dramatic, resulting in loss of consciousness, convulsions, gross imbalance, or other obvious signs of injury [1,2]. In such cases, clinicians should immediately immobilize the cervical spine, assess for emergency conditions and other coexisting injuries, and treat according to the principles of Advanced Trauma Life Support (table 1). This guidance assumes that the clinician has made a firm diagnosis of concussion and that serious injury has been excluded. (See "Concussion in children and adolescents: Clinical manifestations and diagnosis", section on 'Evaluation' and "Concussion in children and adolescents: Clinical manifestations and diagnosis", section on 'Diagnosis'.)

The management of concussions in children and adolescents is based upon observational studies in high school and college athletes, clinical experience, and consensus guidelines [3-9]. Although this topic focuses on sport-related concussions, the principles of management are the same for children and adolescents who sustain concussions from blunt head injury by other mechanisms: [9]

●Initial management – After medical evaluation by a physician, the initial management of concussion focuses on avoidance of additional head injury through removal from competition (if applicable), restriction of physical activity, and relative neurocognitive rest. Cognitive and physical relative rest are the primary initial interventions for concussion [5-12]. The timing for return to school and return to exercise vary from patient to patient depending upon their individual clinical course. Some students who become asymptomatic quickly can return to school and noncontact, low-risk exercise immediately. (See 'Physical rest and activity' below and 'Cognitive rest' below.)

Although small observational studies suggest that athletes suffering from concussions who engage in very high levels of cognitive and physical activity have longer recovery times than those who engaged in low to moderate levels of activity [12,13], care should be taken to prevent physical deconditioning and social isolation in patients with atypical recovery and prolonged symptoms. Those same studies suggest that low levels of activity are not harmful and may in fact be helpful [12-15]. (See 'Physical rest and activity' below.)

●Anticipatory guidance – Anticipatory guidance with education of the patient and parents or legal guardians regarding concussion, including the signs and symptoms, effects on cognition, and typical duration of recovery is also an integral component of clinical management [6]. Because concussion may have no outward sign of injury, friends, teammates, teachers, coaches, and family members may not feel the diagnosis is legitimate and may pressure athletes into excessive physical and cognitive exertion. Education regarding concussion helps to mitigate this stress and to improve compliance with follow-up. As an example, in a multicenter observational study of 354 children (mean age 11 years) undergoing evaluation for concussion in pediatric emergency departments, provision of specific and detailed concussion discharge instructions significantly improved patient follow-up [16].

In preparation for optimal medical management, sports teams should have a written concussion protocol that details how the medical team will respond to a concussion as part of an Emergency Action Plan [17]. The plan should specify:

●Steps involved in the acute field response to a suspected concussion.

●Sideline and in-office evaluations used.

●Medical personnel responsible for decision-making including referral for emergency department evaluation.

●Team discharge instructions given to injured athletes not undergoing emergency evaluation and their families/legal guardians or roommates when they leave the event.

Prevent additional injury — Expert consensus indicates that any child or adolescent with a suspected sport-related concussion should be removed from further competition that day [5,7,9]. The athlete should undergo additional evaluation with a licensed practitioner to determine if a concussion has occurred. If a concussion is diagnosed, the athlete should not return to play until a full recovery has occurred. (See 'Return to play (RTP)' below.)

In addition to removal from organized athletic activities, children and adolescents recovering from concussions should also avoid any recreational activities that may result in a second head injury (eg, cycling, skateboarding, ice skating, or skiing) until they are cleared for competition.

During recovery, athletes suffering from concussions may be particularly vulnerable to worsening symptoms, additional concussions, or potential catastrophic outcomes, such as second impact syndrome if repeated injury occurs. Animal models and observational studies in humans suggest that these additional injuries may occur even with relatively low energy collisions [18-24].

Similarly, patients with concussions caused by other mechanisms should avoid all activities that would place them at risk for additional blunt head trauma during their recovery.

This window of increased brain vulnerability and danger of potentially catastrophic head injury has also been suggested by observational human studies and animal models [19-22,25,26]. As an example, in a case series of 94 incidents of severe head injury while playing American football, 42 percent of athletes had sustained a previous head injury during the same season and almost 40 percent were playing with residual neurologic symptoms at the time of severe head injury [18]. The incidence of injury was significantly higher among high school athletes when compared with college athletes (risk ratio 3.3) possibly due to more high school athletes playing with residual injury; 9 percent of included athletes died. In an observational study of traumatic brain and spinal cord fatalities in high school and college American football players over 10 years, 4 of 22 high school players who died had a history of concussion within the previous four weeks and second impact syndrome was the cause of death in 3 of these 4 patients [27]. Thus, although rare, serious head injury and death may be associated with continued competition too soon after mild head injury.

Physical rest and activity — For children and adolescents with concussions, we recommend a brief period of physical rest lasting 24 to 48 hours followed by a gradual and progressive return to noncontact, supervised, aerobic activity individualized to avoid symptom exacerbation until full recovery, rather than strict physical rest [9,28,29]. If symptoms are worsened by light physical activity, then further activity should be deferred and retried the next day until it can be initiated without worsening of symptoms. Early limited aerobic exercise has been associated with more rapid recovery from concussion [30]. These low levels of exercise are safe and put the athletes in a proactive position, prevent deconditioning, and support the message that school can be attempted.

One way to initiate this activity is to have the child exercising at low levels (stretching and walking limited to "nose-breathing" level of exertion) as soon as they can physically tolerate it, typically after one to two days of rest. From this point, athletes can be advanced gradually as tolerated to more vigorous aerobic activity, to resistance training, to noncontact sport-specific activity according to guidance for return to play. A more rapid return to vigorous exertion is likely to exacerbate symptoms and should be discouraged. (See 'Return to play (RTP)' below.)

While they are recovering from concussion, athletes should also be restricted from activities where they may sustain head injury (eg, contact sports, skiing, skating, or cycling). Incomplete recovery may make the athlete more vulnerable to worsening of symptoms or more catastrophic head injuries in the event of recurrent collisions (ie, second impact syndrome).

Evidence supports sub-symptom threshold physical activity during recovery to decrease concussion symptom scores and duration of symptoms [15,28-35]. For example, in a meta-analysis of seven randomized trials (269 patients, mostly children <18 years), concussion symptoms resolved more quickly in individuals assigned to early return to sub-symptom aerobic activity or multimodal activity (aerobic activity plus visualization and coordination exercise) compared with no prescribed activity (standardized mean difference 0.39, 95% CI 0.15-0.63) [29]. By contrast, strict physical rest beyond 48 hours has been demonstrated to exacerbate self-reported symptoms and should be avoided. For example, in a trial of almost 90 patients (11 to 22 years of age) with concussion, individuals who adhered to strict physical rest for five days had increased symptoms of concussion over 10 days compared with patients who were assigned to usual care (one to two days of rest followed by stepwise return to activity) [31].

Cognitive rest — The available evidence suggests that minimizing of cognitive activities that exacerbate symptoms in concussed patients followed by a gradual resumption of these activities with reassessment by a clinician with expertise in managing pediatric concussions is most likely to result in the shortest duration of symptoms and most timely return to full cognitive function [36].

Our approach to cognitive activity in children and adolescents with concussion is as follows:

●Symptoms worsened by cognitive effort – We suggest that patients who have sustained a concussion, are symptomatic, and have worsening of symptoms by activities such as reading, video games, or screen time minimize activities that make them feel worse, potentially including absence from school [7,37]. Social visits both in and out of the home and trips should be limited if they exacerbate symptoms. During this period of reasonable rest, the child may often engage in light cognitive activities such as watching television, family interaction, and limited amounts of homework without exacerbating symptoms [37,38].

Follow-up with a pediatrician, sports medicine specialist, or other capable provider is needed to help guide the liberalization of cognitive activity. Patients can return to school as soon as they can tolerate 30 to 45 minutes of concentration. In our experience, concussed patients typically benefit from one to two days of reasonable rest before returning to school. To avoid the harm of prolonged absence from school, we usually return student athletes to school after a day or two of rest, with a maximum of five days of rest being rarely recommended.

●Asymptomatic or low-level symptoms – We suggest that patients who are asymptomatic or have low-level symptoms not worsened by routine cognitive activities progress back to full cognitive exertion as tolerated by symptoms. In our experience, exposure to video games, loud music, prolonged screen time, or mental activities requiring high levels of focus and concentration (eg, taking standardized tests) are activities that frequently induce symptoms early in the course of recovery and may need to be avoided for a few days after injury. These patients may continue to attend school.

All children and adolescents returning to school after a concussion warrant monitoring of symptoms and academic accommodations (eg, rest break in the nurse's office or reduced class time (table 2)), as needed, if symptoms are exacerbated by schoolwork or the school environment [28,37]. (See 'Return to learn' below.)

Cognitive rest is designed to avoid overtaxing a functionally injured brain and to prevent metabolic overload [7,37,38]. The recommendation for cognitive rest after a concussion is based upon evidence that suggests a higher rate of prolonged and recurrent symptoms in patients with concussion who engage in higher levels of cognitive activity [12,38-41]. For example, in a randomized trial of 125 adolescents and young adults (mean age 17 years) with acute head trauma who were diagnosed with a concussion during an emergency department evaluation, individuals permitted to have screen time as tolerated on discharge had a longer time to recovery (defined as Post-Concussive Symptom Scale ≤3) compared with those assigned to abstain from screen time for 48 hours after injury (median 8 versus 3.5 days, respectively) [39]. The median reported screen time was 630 minutes in patients with unrestricted screen time compared with 130 minutes in patients advised to abstain from screen time. Limitations of this study include a high loss to follow-up and use of self-report to measure screen time. It is important to note that this study only limited screen time during the first 48 hours after injury. Several observational studies in children, adolescents, and young adults have also found that high cognitive activity after a concussion is associated with prolonged recovery [12,38,40].

On the other hand, the proper degree of cognitive rest and the optimal duration varies from patient to patient. Some experts have noted that prolonged rest with absence from school may be harmful in children and adolescents with concussions, especially in patients with lengthy recoveries [36,42]. Limited evidence also indicates a potential for worsening symptoms in patients with varying degrees of concussion, who are prescribed overly restrictive rest. As an example, in a trial of 99 patients aged 11 to 22 years who were diagnosed with a concussion after pediatric emergency department evaluation (36 percent with loss of consciousness), all subjects reduced physical activity and one group was assigned to strict cognitive rest for five days while the other was assigned to usual care (one to two days of rest followed by gradual return to full cognitive activities) [31,36]. Longer cognitive rest was associated with significantly more daily postconcussive symptoms during the 10 days of follow-up compared with usual care. Strict rest for five days was also associated with an increased duration of symptoms relative to usual care, which was not significant (median of seven versus four days respectively, p = 0.08). There was no clinically significant difference in neurocognitive and balance outcomes at 3 and 10 days after injury as measured by computerized neurocognitive testing or the balance error scoring system (BESS).

Symptom management — Pediatric patients may experience a variety of symptoms while recovering from concussions. In most instances, adherence to physical and cognitive rest followed by gradual resumption of activities will improve symptoms [6,7,43]. Although briefly prescribed medications for symptomatic treatment may be helpful, clinicians should avoid relying too heavily upon pharmaceutical therapies. Under no circumstance should medications be used to mask symptoms with the goal of permitting an athlete to compete. In addition, athletes should not return to play until they are symptom-free while off medications that are prescribed to treat concussion. (See 'Pharmacotherapy' below.)

Headache — Headache is the most common symptom following a concussion (see "Concussion in children and adolescents: Clinical manifestations and diagnosis", section on 'Evaluation'). Recurrent headaches are also an important marker for physical or cognitive overexertion during recovery. While acetaminophen or nonsteroidal antiinflammatory drugs (NSAIDs, such as ibuprofen) are reasonable adjuncts to reasonable physical and cognitive rest during the first few days after injury, they may be ineffective and rebound headaches can complicate treatment and recovery [6,44-47]. Therefore, their prolonged or frequent use beyond the first few days after injury should be discouraged. (See "Medication overuse headache: Etiology, clinical features, and diagnosis".)

Patients with a prior history of migraine headaches may develop a migraine that is triggered by a minor head injury. Initiation of abortive therapy is appropriate if the headache is typical of prior migraine episodes. (See "Acute treatment of migraine in children", section on 'Efficacy of specific drugs'.)

In patients with prolonged headache, the clinician should ensure that there is not a cervicogenic component. Patients with cervicogenic headaches warrant referral for physical therapy and the headache should not be a justification for absence from school. However, these patients should not return to play until the headache resolves. (See "Concussion in children and adolescents: Clinical manifestations and diagnosis", section on 'Primary headache'.)

Nausea — Ondansetron is a reasonable therapy for nausea for the first one to two days after a concussion, especially if it is interfering with eating or drinking. However, ondansetron can cause headaches, drowsiness, and dizziness that may exacerbate other symptoms of concussion. Thus, caregivers should be instructed to stop ondansetron if it makes their child feel worse.

Phenothiazine antiemetics (eg, metoclopramide or promethazine) should be avoided in children and adolescents due to the potential adverse effects of drowsiness, orthostatic hypotension, and in younger patients, acute dystonic reaction.

Sleep disturbance — Children and adolescents with concussion frequently have signs of sleep disturbance including daytime drowsiness, difficulty falling asleep, and difficulty staying asleep. Emphasis on proper sleep hygiene provides the best initial treatment for these patients (table 3A-B). (See "Behavioral sleep problems in children", section on 'Older children and adolescents'.)

Sleep may also be difficult due to symptoms of headache or dizziness. Thus, control of these symptoms may improve sleep as well.

For most patients, sleep will improve with proper sleep hygiene. If pharmacotherapy is necessary because sleep disturbance is prolonging recovery and sleep hygiene has not resulted in improved sleep, then we typically prescribe a trial of melatonin (up to 3 mg in older children and 5 mg in adolescents) [6,48]. The lack of side effects or significant toxicity makes melatonin an attractive choice although efficacy in the setting of concussion is not established [49]. Melatonin is not subject to US Food and Drug Administration (FDA) controls. Thus, preparations may vary in potency and purity.

If melatonin is not effective, then consultation with a pediatric sleep specialist, pediatric neurologist, or pediatric psychiatrist to identify other therapeutic options is an option.

Benzodiazepines should be avoided in patients with concussion because of daytime sleepiness and memory impairment, which hampers the assessment of recovery [6].

Trazodone, a serotonin reuptake inhibitor and antagonist at alpha adrenergic and serotonergic receptors, has been employed with some success for sleep disturbance following traumatic brain injury in adults, but experience in children is limited [48,50]. Furthermore, trazodone is associated with morning hangover and suppresses rapid eye movement (REM) and slow wave sleep.

Dizziness — Dizziness following concussion typically resolves with physical and cognitive rest. For patients with prolonged symptoms, vestibular rehabilitation by a physical therapist may have benefit based upon small observational studies in children and adults [51,52]. (See 'Persistent symptoms' below.)

WORSENING SYMPTOMS — Although the signs and symptoms of concussion can often wax and wane or be exacerbated by either physical or cognitive exertion [9,53], patients who are adherent to prescribed reasonable physical and cognitive rest after a concussion should show gradual improvement in their symptoms. Worsening of their symptoms despite appropriately following a regimen of reasonable physical and cognitive rest should prompt the clinician to evaluate for other potential diagnoses and, if serious intracranial injury cannot be excluded, neuroimaging.

PERSISTENT SYMPTOMS

Multidisciplinary approach — For patients with prolonged postconcussion symptoms (eg, lasting more than three to four weeks), consideration of other contributing etiologies and a multidisciplinary approach is warranted. This approach may include treatment managed by a sports medicine specialist or physician with similar expertise, physical therapist, neuropsychologists, and, in selected patients whose symptoms persist for a month or more, behavioral management by a psychologist or psychiatrist [54]. (See 'Indications for subspecialty referral or consultation' below.)

In a randomized trial of 49 children (11 to 17 years of age) with concussion and persistent symptoms for one month or longer after a sports-related concussion, collaborative treatment consisting of care management, cognitive-behavioral therapy, and, when needed, psychopharmacologic consultation was associated with significant reductions in postconcussive and depression symptoms at six months when compared with usual treatment (87 versus 58 percent of patients without high levels of postconcussive symptoms and 78 versus 46 percent of patients with ≥50 percent reduction in depression symptoms, respectively) [55].

Although debated, the following features of the initial presentation may be associated with prolonged recovery from concussion [56]:

●More severe or numerous initial signs or symptoms (ie, increased symptom load) [57]

●Loss of consciousness for longer than one minute

●Visual and vestibular symptoms (ie, dizziness, vertigo, abnormal gait, or abnormal gaze stability) [58-60]

●Delayed symptom onset [61]

●Number of prior concussions [61]

●Premorbid conditions (eg, prior concussion, headaches including migraine headache, learning disorder, or psychiatric disorder [eg, depression or somatization]) [61-66]

Often, the symptoms can be broken into categories that permit an organized approach to symptom management:

●Physical or somatic symptoms – Headache is a frequent complaint in children and adolescents with persistent symptoms and may be severe enough to be debilitating [43]. Specialty approach to posttraumatic headaches may include several of the following [6,54]:

•Avoidance of nonsteroidal antiinflammatory medications beyond short term, occasional use to prevent the development of rebound headaches

•Specific therapy targeted at the type of headache (eg, tension versus migraine headache)

•Nonpharmacologic therapy, such as biofeedback and psychotherapy

•Preventative pharmacologic treatments

●Visual and vestibular symptoms (eg, balance problems, dizziness, blurred vision) – Patients with visual and vestibular symptoms may benefit from vestibular therapy consisting of progressively applied exercises monitored by a physical therapist [44,51,67-69].

●Psychological or emotional symptoms (eg, irritability, sadness, anxiety, emotional lability) – The direct symptoms of concussion, in addition to the emotional stress related to the restriction placed on activity during recovery, can combine to contribute to depressive symptoms [6]. Prolonged periods of physical and cognitive inactivity can result in symptoms, such as depression, fatigue, headaches, decreased energy, anhedonia, difficulty falling asleep, and others and should be avoided. Indeed, many of these symptoms overlap with those of concussion, making it difficult at times to distinguish between symptoms directly attributable to concussion and those attributable to the physical and cognitive restrictions taken during the course of treatment.

In the minority of patients with prolonged symptoms beyond 10 days after injury, we introduce light, sub-symptom threshold aerobic exercise (eg, light stationary bicycling), which can often be tolerated and may improve symptoms. Engaging in this proactive process can be a psychological boost for these patients and may help mitigate the effects of physical deconditioning. (See 'Physical rest and activity' above.)

However, strenuous physical and cognitive activities that are associated with prolongation of symptoms should be avoided until the patient has fully recovered. (See 'Prolongation of symptoms' below.)

Psychologic assessment and counseling by a psychologist or psychiatrist with an emphasis on the temporary nature of the restrictions and the good prognosis is appropriate for athletes who continue to experience these symptoms. If prolonged, initiation of antidepressant medication by a psychiatrist may be warranted.

●Cognitive symptoms (eg, confusion, feeling in a fog, difficulty remembering, difficulty concentrating) – Attention to somatic, vestibular, psychological, and sleep symptoms associated with prolonged concussion frequently secondarily improves cognitive symptoms. Although pharmacologic therapy has shown some success in improving neurocognitive function in small observational studies, its use for this purpose should be confined to clinicians who are experienced in the management of sports-related concussion or concussive brain injury and who are familiar with the risk-benefit profile of the medications [6,54]. Furthermore, accelerated recovery from a concussion has not been shown [70]. Academic adjustments or accommodations are typically instituted for these types of symptoms. (See 'Return to learn' below.)

●Sleep disruption (eg, trouble falling asleep, sleeping more than usual) – The management of sleep disruption should start with proper sleep hygiene recommendations (table 3A) [6,45,50,71]. Carefully monitored physical exercise and return to learning may also help to normalize the athlete's schedule and positively impact sleep. In addition, melatonin use as described above provides pharmacologic therapy that has little to no risk. Prolonged use of sedatives should be avoided. (See 'Sleep disturbance' above.)

Pharmacotherapy — No medications have been proved to speed recovery from concussion or prevent long-term effects from injury [72].

The following conditions should be met before a trial of medication is provided:

●The patient's symptoms have exceeded the typical recovery period for a sport-related concussion.

●The symptoms are negatively affecting the patient's quality of life to such a degree that the possible benefit of treatment outweighs the potential risks of the medication being considered.

●The clinician caring for the patient is knowledgeable and experienced in the assessment and management of sport-related concussion or concussive brain injury in general.

A discussion of specific medications for the management of concussion other than those mentioned above is beyond the scope of this topic but is reviewed in the references [6,73,74].

INDICATIONS FOR SUBSPECIALTY REFERRAL OR CONSULTATION — Many young athletes with sport-related concussions are managed by athletic trainers or primary care physicians. Children and adolescents with concussion caused by other mechanisms also commonly follow-up with their primary care provider. Patients with the following findings warrant referral to a physician with specific expertise in managing pediatric concussion (eg, sports medicine specialist, physiatrist, neurosurgeon, or neurologist):

●Persistent symptoms of concussion (eg, persistent symptoms 21 days or longer after injury) (see 'Persistent symptoms' above)

●Patients with multiple concussions occurring with progressively less force and/or associated with more intense symptoms or greater cognitive dysfunction (see 'Retirement from contact sports' below)

●Uncertain diagnosis of concussion

RETURN TO LEARN — Once patients can concentrate on a task and tolerate visual and auditory stimulation for 30 to 45 minutes (or approximately the length of the average school period), they should return to school with academic adjustments, as needed, until full recovery. The figure provides a sample school note for the physician (table 4).

Adjustments may include [37,46,75]:

●Limited course load

●Shortened classes or school day

●Increased rest time

●Aids for learning (eg, class notes or supplemental tutoring)

●Postponement of high-stakes testing (eg, the Scholastic Aptitude Test [SAT] or Advanced Placement tests)

A wide variety of other potential adjustments may also be offered depending upon the symptoms that are most troublesome (table 2). Hence, the return to school must be individualized and requires monitoring by the parent or legal guardian, school faculty, and managing physician.

Notifying the school academic team (teacher, school counselor, school nurse or physician, physical education teacher, school coach, athletic trainer, and school administrator) of the presence of the concussion is the responsibility of the parent or legal guardian [37]. They must also sign a release of information for school personnel to be able to coordinate appropriate adjustments as recommended by the primary clinician managing the concussion. In general, participation in school-sponsored extra-curricular activities, including athletics, is typically not allowed until the athlete is fully back to school.

For athletes with prolonged symptoms lasting beyond three weeks, academic accommodations, as determined by the school system's regulations, polices, and practices, may be needed rather than adjustments [37]. As opposed to academic adjustments, academic accommodations are designed to provide a specific individualized education plan for student instruction that will address specifically identified learning deficits based upon professional (eg, psychological or neuropsychological) testing. For most patients, referral to a specialist (eg, sports medicine specialist, neurologist, or neurosurgeon) with expertise in managing concussions is warranted for such patients. (See 'Indications for subspecialty referral or consultation' above.)

Accommodations are also intended to keep schoolwork at a manageable level and to permit full recovery. Given the quantitative deficits in cognitive function that occur with concussion, especially in executive function, processing speed, concentration, and memory [63,76-78], such academic support is frequently needed [28]. Students, the school academic team, and parents or legal guardians should work together to keep up with as much current work as tolerable while planning to make up missed work as efficiently as possible after recovery. For patients who suffer prolonged recoveries, plans to make up incomplete work may include assignments during scheduled school breaks or summer vacation [6,46,75,79].

For older children and adolescents with concussion, early return to school within one to two days after injury may also be associated with more rapid recovery. For example, in a prospective observational study of over 1600 children with concussion, an early return to school (≤2 days after concussion) was associated with lower symptom burden 14 days after injury for individuals 8 to 18 years old [80]. This association was stronger for patients with a higher initial symptom burden and suggests a possible benefit for early school return among the patients with the most symptoms at diagnosis. Early return to school for five- to seven-year-olds was not associated with a lower symptom burden at 14 days.

Neuropsychological testing — Because cognitive recovery may lag behind physical recovery, clinicians frequently use computerized neurocognitive or neuropsychological testing to help determine when the patient has fully recovered from a concussion.

Both traditional pen-and-paper neuropsychological assessments and computerized neurocognitive assessments have been used for assessing patients [76,81,82]. Each has advantages and disadvantages. Traditional neuropsychological testing is more thorough and can be tailored to meet the needs of each patient. Interpretation by a neuropsychologist permits the assessment of other potential factors that may be affecting test performance. Furthermore, assessment by a neuropsychologist has the added advantage of an additional clinical opinion.

However, pen-and-paper testing typically takes several hours. Also, many patients may not have access to a neuropsychologist. In addition, pen-and-paper testing is relatively costly and health insurance may not cover the cost of testing. Thus, traditional neuropsychological testing is often not a practical approach to measuring and managing cognitive recovery in concussed children and adolescents.

Computerized neurocognitive assessments are convenient (administration time approximately 30 minutes) and permit tests to be administered by other medical personnel after test specific training has been completed. They have become common for assessing and managing pediatric athletes with concussion [3,4,83]. Furthermore, preparticipation baseline computer testing is much more easily performed for a sports team than traditional pen-and-paper assessments. When selecting a computerized test, it should be one that has shown validity in children and adolescents [7]. (See "Concussion in children and adolescents: Clinical manifestations and diagnosis", section on 'Preparticipation assessment'.)

In patients with prolonged symptoms, computerized medical symptom validity testing [84] may be warranted to assess whether symptoms are faked or exaggerated [85].

RETURN TO PLAY (RTP) — We suggest that young athletes fully complete the consensus graduated return to play protocol after an individualized period of cognitive and physical rest before clearance for competition.

Prior to returning to full athletic participation, recovered athletes should complete a course of non-contact exercise challenges of gradually increasing intensity [5,9,11]. The graded RTP protocol advances through the following rehabilitation stages: light aerobic exercise, more intensive training, sports-specific exercises, non-contact participation, full practice, and ultimately, game play as shown in the table (table 5).

The following are requirements for children and adolescents to begin the RTP protocol:

●Successful return to school.

●Symptom-free and off any medications prescribed to treat the concussion.

●Normal neurologic examination.

●Back at baseline balance and cognitive performance measures. If baseline assessments are unavailable, age-adjusted normative data are available and can be useful in attempting to estimate premorbid levels of functioning for a given athlete. Given the variability in performance between athletes, however, baseline data are ideal. (See "Concussion in children and adolescents: Clinical manifestations and diagnosis", section on 'Preparticipation assessment'.)

Athletes should be symptom-free during and after exertion at a given activity level before progressing to the next level. According to the American Academy of Pediatrics and the Concussion in Sport Group consensus statement, children and adolescents should remain at each stage of rehabilitation no less than 24 hours before advancing to the next level. Thus, a minimum of five days should pass before consideration of full return to competition [5,9]. Furthermore, some clinicians recommend building in an additional symptom-free waiting period and some jurisdictions have legislation requiring a minimum number of symptom-free days prior to returning to play. The clinician should be aware of any such laws or local recommendations.

If there is return of symptoms at any level, the athlete should rest until the symptoms resolve, and then attempt the protocol again beginning at the previous level of symptom-free exertion.

There may be advantage to allowing low-risk, non-contact aerobic activity prior to full symptom resolution, particularly in those athletes with prolonged symptoms. Such a decision should be made by those with expertise in the management of sport-related concussions.

Because of the concern for complications and permanent brain injury that are associated with overly aggressive return to play in children and adolescents, we have athletes younger than 13 years of age and those at higher risk (eg, longer duration of symptoms, higher numbers of previous concussions, or returning to higher risk sports) engage in a longer symptom-free waiting period before returning to play. For instance, a 12 year-old athlete recovering from a second lifetime concussion, with symptoms that took longer than four weeks to resolve should consider one week of success at each of the stages of exercise progression before returning to a high-risk sport, such as American football or ice hockey. Some clinicians have advocated a requirement of equal number of symptom-free weeks as there were symptomatic weeks during recovery before return to contact practice and play is considered.

Thus, the plan for RTP after a concussion should be individualized, gradual, and progressive. This progression permits the athlete to restore confidence, sharpen skills, and simulate sports-specific activity in a controlled setting before entering competitive play. The final decision for RTP should be made by a licensed clinical provider with experience in the evaluation and management of sports-related concussions. The prognosis for RTP cannot be easily predicted by the presenting features of a concussion. Full RTP exercise progression may take days, weeks, or months although most athletes will be cleared to play within one month [3,4]. (See 'Prognosis' below.)

RETIREMENT FROM CONTACT SPORTS — Decisions regarding retirement from contact sports are difficult to make and should be done in conjunction with a clinician experienced in the assessment and management of sport-related concussions [5]. Ancillary testing, such as neuroimaging or formal neuropsychological testing, may also be helpful.

Retirement from contact sports is usually indicated for patients with structural brain abnormality on neuroimaging or nonresolving or prolonged neurocognitive deficits by neuropsychological or other functional testing (eg, functional magnetic resonance imaging).

Retirement from contact sports is often also appropriate for patients with the following findings:

●Increased recovery times or for successive injuries

●A pattern of decreased threshold for repeat concussions, especially when associated with persistent prolonged symptoms

●Multiple concussions over the course of an athletic career

Although the number of diagnosed concussions is an important factor when considering retiring from contact and collision sports, it is not the only factor. Other items to consider include [86,87]:

●Are the symptoms experienced after concussion of increasing intensity?

●Is the cognitive dysfunction experienced after a concussion becoming more severe?

●Is the sport and position high-risk?

PROGNOSIS — Most pediatric patients will recover readily from concussions [3-5,9,62,88-90]. As an example, over 90 percent of high school athletes who sustain a sport-related concussion and are seen by a medical provider will be symptom-free and cleared for play within one month of injury [3,4]. Furthermore, in a large study of over 2700 pediatric patients, 5 to 18 years of age, who presented to the emergency department with acute concussions, over 80 percent of children and adolescents recovered within four weeks [91]. On adjusted analysis, adolescent female patients took longer to recover, with less than one-half reaching full recovery by 12 weeks compared with over 80 percent of adolescent males having full recovery by 4 weeks.

However, some patients will take several months to recover from their concussions. Many factors have been proposed as predictive of prolonged recovery from a concussion including a history of prior concussions, female sex, history of migraines, history of learning disabilities, recurrent concussion soon after recovery, or degree of symptoms after a concussion [7,62,92-95]. Of these, observational evidence suggests that increased severity of symptoms at presentation and, among adolescents, female sex are the primary factors associated with prolonged recovery from a concussion [12,57,92,96].

COMPLICATIONS — While most concussions readily resolve, complications may occur, especially when concussions are not recognized or are sustained multiple times over the course of an athletic career, including prolongation of symptoms, second impact syndrome, and chronic traumatic encephalopathy.

Prolongation of symptoms — Expert opinion and clinical experience suggest that strenuous cognitive and physical exertion during the earlier parts of recovery may prolong or exacerbate the symptoms of concussion [12,13]. As an example, in an observational study of 95 teenage athletes, high levels of activity after a concussion was associated with poorer neurocognitive performance (eg, verbal and visual memory, visual motor speed, and reaction time) [13].

On the other hand, overly restrictive cognitive or physical rest may also be associated with prolonged symptoms, suggesting that cognitive and physical rest should be carefully monitored and tailored to each patient's response. (See 'Physical rest and activity' above and 'Cognitive rest' above.)

Second impact syndrome — Second impact syndrome refers to death or devastating neurological injury attributable to massive swelling of the brain in athletes who sustain a second head injury prior to full recovery from a concussion. Although some debate exists about whether or not a prior concussion is necessary, or whether the resultant edema can be due to a primary injury alone, young athletes who return to contact or collision sports while still recovering from a concussion may be at significant risk and should not return to play or engage in other activities that place them at increased risk of head injury (eg, bicycle riding or skateboarding) until fully recovered. (See 'Prevent additional injury' above and "Sequelae of mild traumatic brain injury", section on 'Second impact syndrome'.)

Chronic traumatic encephalopathy — Chronic traumatic encephalopathy (CTE) refers to specific pathological changes in the brain observed post-mortem. It has been hypothesized that these pathological findings are associated with changes in mood, behavior, cognition, somatic symptoms, and, in severe cases, dementia or Parkinsonian symptoms occurring in patients with multiple concussions sustained over the course of an athletic career. CTE has been described in boxers, American football players, and military personnel exposed to combat-related blast injuries. (See "Sequelae of mild traumatic brain injury", section on 'Chronic traumatic encephalopathy'.)

Although concern has been raised about athletes sustaining repetitive head impacts and multiple concussions being at increased risk for neurodegenerative diseases such as CTE or Alzheimer disease, the evidence is inconclusive as to whether multiple concussions in youth are associated with long-term neurologic changes [97]. (See "Sequelae of mild traumatic brain injury", section on 'Chronic traumatic encephalopathy'.)

Avoidance of CTE is frequently a rationale for advising retirement from contact and collision sports. (See 'Retirement from contact sports' above.)

PREVENTION — For the prevention of concussion, evidence supports concussion education programs, age limits on body-checking (ice hockey) or tackling (American football), mouth guards, and proper enforcement of rules and fair play among young athletes as follows [9,87]:

●Education – Studies in young athletes and youth coaches indicate that educational programs are associated with increased attainment of knowledge about the recognition and seriousness of concussions [87]. However, change in behavior has not been well studied and persistent tendencies among high school athletes to potentially hide symptoms so as not to appear weak or let the team down have been reported. For example, in a survey of 167 high school athletes, 60 percent of concussions events were not disclosed to an adult [98]. Similarly, less than one-half of 229 high school American football players who had a concussion during the previous season reported the injury to a trainer, physician, or coach [99]. Furthermore, in a prospective observational study approximately 40 percent of 59 elite female soccer players played despite symptoms of concussion and 56 percent never saw a qualified health professional [100]. Factors associated with an increased likelihood of reporting a concussion included approval of such reporting by peers, coaches, and parents/primary caregivers; a positive view of reporting by the individual, and ease of reporting [101].

Anticipatory guidance by the primary care physician is another method of education for the student athlete and parents/primary caregivers. The Head's Up program is an excellent resource that has been developed by experts in head injury and the Centers of Disease Control and Prevention to help educate health care providers, athletes, coaches, school staff and parents/primary caregivers about concussion.

●Age limits on types of physical contact – Based upon observational studies that show an association between body checking and an increased risk of injury, including concussion [102-105], the American Academy of Pediatrics recommends that body checking not be permitted in youth hockey until the age of 15 years [106].

Evidence suggests that limiting certain types of contact during ice hockey until an older age is an effective strategy to reduce the risk of concussion during the season in which body checking is prohibited but may be associated with a higher risk of more severe injuries, other than concussions, in older players who lack checking experience in subsequent seasons [102,107,108]:

•Based upon prospective surveillance of injuries in over 1500 hockey players 11 and 12 years of age before and after raising the age for body checking to 13 years nationwide in Canada, the rate of concussions decreased by 64 percent among 11 and 12 year-old players (2.8 concussions per 1000 game-hours before to 1.1 concussions per 1000 game-hours after the rule change) [107].

•In another study that compared the risk of injury and concussions between two Canadian provinces (almost 2200 players), one where body checking was allowed for 11- to 12-year-old players and one where body checking was not allowed for this age group, risk of injury or concussions was significantly increased in the league that permitted body checking (incidence rate ratio 3.9 for all injuries and 3.3 for concussions) [102]. In a follow-up to this study, once checking was permitted at the ages of 13 and 14 years for both Canadian provinces, concussion rates did not differ significantly between the groups, but players introduced to body checking for the first time at that age had a significantly higher risk of injuries resulting in seven days or more time loss from hockey compared with players who had at least two years of previous body checking experience (2.2 versus 1.5 injuries per 1000 player-hours) [108].

Further investigation is needed to determine if the higher observed risk of other injuries can be mitigated by interventions such as on and off ice exercises designed to teach younger players how to absorb a body check without being injured during seasons when checking is not permitted.

Evidence is lacking concerning whether restrictions on tackling in American football can reduce concussions [97]. In a preliminary study that compared the incidence of injury between tackle football and flag football leagues, the incidence of severe injuries or concussions was not significantly different [109]. Total injuries were more frequent in flag football leagues, but tackle football injuries resulted in a significantly longer time before return to play.

●Mouth guards – A meta-analysis of 39 studies found that use of mouthguards by ice hockey players was associated with a 28 percent reduction in concussion across all age groups [110]. These findings suggest that mouth guards may prevent concussion in children and adolescents engaged in collision sports such as football, ice hockey, or rugby. Evidence is lacking on whether mouth guards prevent concussions in non-collision sports such as soccer, basketball, field hockey, or women's lacrosse.

●Fair play – Observational studies of youth and high school sports show that adherence to the rules of the sport and encouragement of fair play is associated with decreased injuries, including concussions [87]. For example, greater accelerations of the head and many concussions in sports occur during illegal play, when athletes do not anticipate the collision, or when athletes use improper technique [111-113]. Thus, proper coaching technique and adherence to the rules of play may reduce the overall incidence of concussion [114,115].

By contrast, existing evidence does not support the ability for helmets to prevent concussion [87,97,116]. Furthermore, injury risk rating systems provided by equipment manufacturers have not been shown to correlate with actual concussion risk. Although new devices are available that can noninvasively monitor the number and magnitude of head impacts, further study is needed to determine if this information can identify players that should be removed from competition [87].

However, the associated reduction of catastrophic brain injuries for athletes who wear helmets warrant their continued promotion. Similar evidence also supports the use of helmets when performing high risk activities outside of organized sports (eg, climbing, riding bicycles or motorcycles, or skiing) and the use of seat belts or appropriate car seats to protect children and adolescents during motor vehicle collisions. (See "Evaluation and management of dental injuries in children", section on 'Mouthguards' and "Bicycle injuries in children: Prevention", section on 'Bicycle helmets'.)

In theory, strengthening of the muscles of the neck and posterior shoulders might reduce the risk of sports-related concussion by reducing acceleration during direct or indirect head trauma [112,117-120]. However, evidence is lacking on the benefit of this approach and recommending neck strengthening exercises may be counterproductive because young athletes may believe they are protected against concussion by doing these exercises and may engage in dangerous play.

Impact of legislation — Laws designed to encourage identification of concussion and to prevent concussed youth athletes from continuing play exist in all 50 of the United States. These laws, modeled after the Zackery Lystedt Law, which was named after a 13-year-old middle school boy who suffered permanent brain injury when he continued to play in a football game despite having a concussion and was enacted in Washington State in 2009, consist of three components:

●Mandatory removal of athletes with confirmed or suspected concussion from play

●Clearance from a licensed health professional before athletes may return to play

●Annual education of coaches, parents/primary caregivers, and athletes on the signs and symptoms of concussion

Adoption of these laws has been associated with a decrease in the incidence of recurrent concussions among United States high school athletes [121]. Passage of this legislation has also been associated with increased reporting of new concussions from the prelaw through the post law period, likely attributable to increased awareness and identification of concussions.

ADDITIONAL RESOURCES — The following resources provide additional educational materials related to concussion and mild traumatic brain injury in children and adolescents:

●A sample form for physicians to use to provide guidance on academic accommodations is provided (table 4).

●The Acute Concussion Evaluation (ACE) tool that is part of these educational materials has been adapted for use in the emergency department as described in the following reference [16].

●The Centers for Disease Control and Prevention Pediatric Mild Traumatic Brain Injury Guideline, provider tools, and patient and family resources are available here.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Increased intracranial pressure and moderate-to-severe traumatic brain injury" and "Society guideline links: Minor head trauma and concussion" and "Society guideline links: Sports-related concussion".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topic (see "Patient education: Concussion in children and teens (The Basics)")

SUMMARY AND RECOMMENDATIONS

●Approach – After excluding serious injury to the head or neck, the initial management of concussion in children and adolescents consists of:

•Prevent further head injury – Any child or adolescent with a suspected sport-related concussion should be removed from further competition that day and not return to play until after evaluation and medical clearance by a licensed practitioner. Patients with concussions, regardless of mechanism, should also avoid any recreational activities that may result in a second head injury (eg, cycling, skateboarding, ice skating, or skiing) until they have fully recovered. (See 'Prevent additional injury' above and "Sideline evaluation of concussion".)

•Physical rest – For children and adolescents with concussions, we recommend a brief period of physical rest lasting 24 to 48 hours followed by a gradual and progressive return to noncontact, supervised, aerobic activity individualized to avoid symptom exacerbation until full recovery, rather than strict physical rest (Grade 1B). (See 'Physical rest and activity' above.)

•Cognitive rest – For children and adolescents with a concussion whose symptoms are made worse by activities such as reading, video games, or screen time, we suggest reasonable rest consisting of light cognitive activities such as watching television, family interaction, and limited amounts of homework that do not exacerbate symptoms with gradual progression as tolerated (Grade 2C). Social visits both in and out of the home and trips should be allowed as tolerated. (See 'Cognitive rest' above.)

In symptomatic patients, close follow-up with a pediatrician, sports medicine specialist, or other capable provider is needed to help guide the liberalization of mental activity. Patients can return to school as soon as they can tolerate 30 to 45 minutes of concentration (typically one to two days after injury). To avoid the harm of prolonged absence from school, we usually return student athletes to school as soon as it is tolerated. For athletes who report intolerance to school for more than a few days, we explore other potential etiologies contributing to their symptoms. (See 'Cognitive rest' above and 'Return to learn' above.)

For patients who are asymptomatic or have low-level symptoms not worsened by routine cognitive activities, we suggest progressing back to full cognitive exertion as tolerated by symptoms (Grade 2C). In our experience, exposure to video games, loud music, prolonged screen time, or mental activities requiring high levels of focus and concentration (eg, taking standardized tests) are activities that frequently induce symptoms and need to be curtailed for a few days after injury. These patients may continue to attend school. (See 'Cognitive rest' above.)

●Return to school – All children and adolescents returning to school after a concussion warrant monitoring of symptoms and academic adjustments (eg, rest break in the nurse's office or reduced class time (table 2)), as needed, if symptoms are exacerbated by schoolwork or the school environment. (See 'Return to learn' above.)

●Symptom management – Children and adolescents may experience a variety of symptoms while recovering from concussion. In most instances, adherence to reasonable physical and cognitive rest will improve symptoms. Although briefly prescribed medications for symptomatic treatment (eg, acetaminophen or ibuprofen for headache) may be helpful, clinicians should avoid prolonged use of pharmaceutical therapies. Under no circumstance, should medications be used to mask symptoms with the goal of permitting an athlete to compete. (See 'Symptom management' above.)

●Return to play – For all athletes with a confirmed concussion, we suggest the consensus graduated return to play (RTP) protocol (table 5) after an individualized period of cognitive and physical rest before clearance for competition (Grade 2C). The following are requirements for children and adolescents to begin the RTP protocol (see 'Return to play (RTP)' above):

•Successful return to school.

•Symptom-free and off any medications prescribed to treat the concussion.

•Normal neurologic examination.

•Back at baseline balance and cognitive performance measures. If baseline assessments are unavailable, the clinician may use age-adjusted normative data to inform the decision, along with other clinical parameters. (See "Concussion in children and adolescents: Clinical manifestations and diagnosis", section on 'Preparticipation assessment'.)

Because cognitive recovery may lag behind physical recovery, neuropsychological testing may also be helpful in determining when the patient has fully recovered from a concussion. (See 'Neuropsychological testing' above.)

●Worsening or persistent symptoms – Worsening of the patient's symptoms despite appropriately following a regimen of physical and cognitive rest should prompt the clinician to evaluate for other potential diagnoses and, if serious intracranial injury cannot be excluded, neuroimaging. (See 'Worsening symptoms' above.)

Patients with the following findings warrant referral to a physician with specific expertise in managing pediatric concussion (eg, sports medicine specialist, physiatrist or neurologist) (see 'Indications for subspecialty referral or consultation' above):

•Prolonged symptoms of concussion (eg, persistent symptoms 21 days or longer after injury).

•Patients with multiple concussions occurring with progressively less force and/or associated with more intense symptoms or greater cognitive dysfunction. (See 'Retirement from contact sports' above.)

•Uncertain diagnosis of concussion.