Return‑to‑Play Protocol for Pediatric Concussion

Absolute Contra‑indications

• Athletes must not return to play on the same day of injury under any circumstances; this applies to all pediatric and adolescent athletes. American Academy of Pediatrics recommendation. 1
• Return is prohibited while any concussion‑related symptoms are present, whether at rest or during exertion. American Academy of Pediatrics recommendation. 4
• Athletes cannot progress while taking medications that mask concussion symptoms (e.g., analgesics, sedatives). Journal of Neurosurgery guidance. 5
• Medical clearance from a licensed health‑care professional trained in concussion management is required before advancing beyond the initial rest phase. American Academy of Pediatrics recommendation. 2

Structure of the Graduated 6‑Step Protocol

• The protocol consists of six sequential steps, each requiring a minimum of 24 hours before progression; the fastest possible return to full competition is 5 days after initiating step 1. American Academy of Pediatrics guideline. 6

Step 1 – Complete Physical and Cognitive Rest

• Athletes must achieve asymptomatic status at rest (both physical and cognitive) before moving to step 2. American Academy of Pediatrics guideline. 3
• In pediatric/adolescent athletes, cognitive recovery typically lasts 7–10 days or longer compared with older athletes. American Academy of Pediatrics data. 1

Step 2 – Light Aerobic Activity

• Allowed activities: walking, swimming, stationary cycling ≤ 70 % of maximum heart rate; no resistance training is permitted. American Academy of Pediatrics recommendation. 6
• The goal is to increase heart rate without provoking symptoms. American Academy of Pediatrics observation. 3

Step 3 – Sport‑Specific Exercise (No Head Impact)

• Perform sport‑related drills that avoid any head impact (e.g., skating for hockey, running for soccer). Consensus Statement on Concussion in Sport (British Journal of Sports Medicine). 4

Step 4 – Non‑Contact Training Drills

• Introduce more complex, non‑contact drills; light resistance training may begin, but no contact or collision activities are allowed. American Academy of Pediatrics guideline. 7

Step 5 – Full‑Contact Practice

• After medical clearance, athletes may engage in normal full‑contact training while remaining asymptomatic throughout. Consensus Statement on Concussion in Sport (British Journal of Sports Medicine). 4

Step 6 – Return to Play

• Athlete resumes full competition with no restrictions. American Academy of Pediatrics guideline. 6

Management of Symptom Recurrence

• If symptoms return at any stage, the athlete must stop activity immediately, rest ≥ 24 hours until asymptomatic, and regress to the previous symptom‑free step before attempting progression again. American Academy of Pediatrics and Consensus Statement guidance. 4
• The athlete should contact the health‑care provider if symptoms recur. American Academy of Pediatrics recommendation. 1

Populations Requiring Extended Protocols

• Multiple prior concussions mandate a longer, more cautious progression. American Academy of Pediatrics observation. 3
• Prolonged symptom duration (> 10 days) also necessitates an extended timeline. Journal of Neurosurgery guidance. 5

When to Refer for Specialist Management

Monitoring & Documentation

• Parents or athletic trainers may monitor step progression with proper instruction. American Academy of Pediatrics recommendation. 6
• The precautionary principle “When in doubt, sit them out!” should guide all RTP decisions. American Academy of Pediatrics and Consensus Statement endorsement. 4