Diagnosing and Managing Pediatric Concussion

July 25, 2014

Diagnosing and Managing Pediatric Concussion

  1. Katherine Bakes, MD

Comprehensive guidelines for children aged 5 to 18 years with suspected concussion

  1. Katherine Bakes, MD

Sponsoring Organization: Ontario Neurotrauma Foundation

Target Population: Healthcare professionals and others who deal with concussion, including physicians, neuropsychologists, physical therapists, family, and schools/community sports organizations

Background and Objective

The panel used an evidence-based, systematic review to standardize diagnosis, assessment, and management of children (age range, 5–18 years) with suspected concussion.

Key Recommendations

Red flags
Red flags
  • For children participating in high-risk sports (contact and collision sports), consider baseline neurocognitive testing.

  • On initial presentation, assess and treat physical, cognitive, and other neurologic deficits:

    • Manage acute symptoms, including identifying any so-called red flags (see table) and assessing need for emergent neuroimaging.

    • Perform an acute concussion evaluation based on a standardized tool.

    • Prescribe physical and cognitive rest.

  • On discharge, provide education and a postconcussion care plan with explicit direction for teachers and school-based activities:

    • Educate about the risks for persistent symptoms including managing sleep, headaches, and fatigue.

    • Counsel patients on avoiding alcohol, recreational drugs, and driving during recovery.

    • Instruct patients to have close primary care follow-up and referral to a specialist in concussion management if symptoms persist beyond 1 month.

  • On interim assessment, have return-to-learn and return-to-play stepwise plans and refer children with multiple concussions to specialized care by a concussion expert.

  • At 1 month, if symptoms persist, patients should undergo a more comprehensive health evaluation to:

    • Look for underlying physical or mental health modifiers.

    • Consider a program of sleep hygiene.

    • Prescribe short-term medications as needed for sleep and headaches.

    • Refer patients with neurocognitive or mental health needs to relevant specialists.


This guideline provides a standardized approach to assess and manage pediatric concussions. Effective execution relies on multidisciplinary buy-in and accessibility. After the emergency department or other primary encounter, the primary care provider should monitor symptoms and recovery, working with the school and family for a safe return to learning and other activities. Fortunately, most students with a concussion will recover within the first 3 weeks of their injury. The guideline agrees, in general, with the American Academy of Pediatrics clinical report “Returning to Learning Following a Concussion” (NEJM JW Emerg Med Nov 26 2013).

Editor Disclosures at Time of Publication

  • Disclosures for Katherine Bakes, MD at time of publication Grant / Research support Department of Justice Editorial boards Elsevier Emergency Medicine Secrets


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