Return to Play Protocol for Pediatric Concussion

General Guidelines

The American Academy of Pediatrics recommends that pediatric and adolescent athletes with concussion must never return to play on the same day of injury and should follow a structured 6-stage graduated protocol requiring a minimum of 5 days, with each stage lasting at least 24 hours 1
No child or adolescent should return to play on the same day of concussion, regardless of symptom resolution, as stated by the American Academy of Pediatrics 1, 2
Athletes must be completely asymptomatic both at rest and with exertion before beginning the return-to-play protocol, according to the American Academy of Pediatrics 1
Medical clearance from a licensed healthcare professional trained in concussion management is mandatory before return to play, as recommended by the American Academy of Pediatrics 2

The American Academy of Pediatrics endorses a stepwise progression, with each stage requiring a minimum of 24 hours, including Stage 1: Complete Rest, where complete physical and cognitive rest is required until asymptomatic at rest 1, 3
Stage 1 also includes restriction from school work that may exacerbate symptoms, as recommended by the American Academy of Pediatrics 4
Stage 2: Light Aerobic Activity, includes walking, swimming, or stationary cycling at ≤70% maximum heart rate, with no resistance exercises permitted, as stated by the American Academy of Pediatrics 1
Stage 4: Non-Contact Training Drills, involves more complex training drills with progression of exercise, and light resistance training may begin at this stage, according to the American Academy of Pediatrics 1
Stage 5: Full-Contact Practice, requires return to normal training activities after medical clearance, with participation in all typical practice drills including contact, as recommended by the American Academy of Pediatrics 1
Stage 6: Return to Play, involves normal game participation, as stated by the American Academy of Pediatrics 1

Pediatric athletes require longer recovery than adults—typically 7-10 days or longer for full cognitive recovery, even after becoming asymptomatic, as reported by the American Academy of Pediatrics 1, 5
A minimum of 5 days is required to progress through all stages if no symptoms recur, according to the American Academy of Pediatrics 1
Most pediatric athletes become asymptomatic within one week, but cognitive recovery takes longer, as stated by the American Academy of Pediatrics 5
If symptoms recur at any stage, the athlete must stop immediately, wait 24 hours after becoming asymptomatic again, then resume at the previous asymptomatic level, as recommended by the American Academy of Pediatrics 1

If symptoms return during any stage of the protocol, immediately cease that activity level, as stated by the American Academy of Pediatrics 1
After remaining asymptomatic for at least 24 hours, attempt the previous stage again before progressing, according to the American Academy of Pediatrics 1
Athletes should contact their healthcare provider if symptoms recur during the protocol, as recommended by the American Academy of Pediatrics 1

Athletes with multiple concussions or prolonged symptoms require longer, individualized rehabilitation programs created by physicians experienced in concussion management, as stated by the American Academy of Pediatrics 1
Consider prolonged time away from sports for any athlete with 3 concussions in one season or postconcussive symptoms lasting more than 3 months, as recommended by the American Academy of Pediatrics 6
Teachers and administrators must modify workloads to avoid symptom exacerbation during cognitive recovery, according to the American Academy of Pediatrics 6

The phrase "When in doubt, sit them out" is paramount in pediatric concussion management, as stated by the American Academy of Pediatrics 1, 2
The longer cognitive recovery period in children compared to adults makes conservative management essential for preventing long-term complications, as reported by the American Academy of Pediatrics 1