Cerebral concussion in childhood …

Brittany Poinson MD MSEd

General Neurology

Updated 01.21.2026
Released 07.21.2012
Expires For CME 01.21.2029

Cerebral concussion in childhood

Author: Brittany Poinson MD MSEd

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Editor: Alcy R Torres MD FAAP

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Cerebral concussion in childhood

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Introduction

Overview

Concussion, or mild traumatic brain injury, is a complex, multifactorial condition that has garnered increasing global attention. Despite heightened awareness, diagnosis remains challenging due to variability in clinical presentation and ongoing debate regarding diagnostic criteria. This article will summarize current definitions, clinical features, prognostic indicators, and contemporary management recommendations for pediatric concussion.

Concussion results from the transmission of biomechanical forces to the brain, triggering a cascade of neurometabolic events that cause functional disturbance without detectable structural injury (104). Pediatric patients demonstrate unique susceptibility to concussive injury due to differences in stature, head-to-body ratio, and nervous system physiology. As in adults, concussion symptoms reflect disruption of global brain function, encompassing cognitive, emotional, physical, and sleep-related domains (32). However, recovery in children is frequently prolonged compared with adults (48).

Management of pediatric concussion requires consideration of the cognitive demands of school and ongoing development. Recommended strategies include immediate removal from play following injury, a brief period of cognitive (24 to 48 hours) and physical rest, evaluation by a clinician trained in concussion management, structured return-to-learn protocols with academic accommodations, and, on medical clearance, a supervised, gradual return-to-play program. Earlier schooling with support and early sub-symptom aerobic exercise are now favored over prolonged strict rest. This article reviews strategies based on increasing evidence that supports early, symptom-limited activity and timely return to school rather than prolonged strict rest, which may delay recovery. Early and appropriate intervention is essential, as children are at risk for rare but potentially catastrophic complications, such as second impact syndrome and diffuse cerebral swelling.

Current management recommendations presented in this review are aligned with the American Academy of Pediatrics 2023 evidence reviews on early physical activity and school reintegration, as well as the CDC HEADS UP 2024–2025 guidance, which provides practical algorithms and tools used by clinicians, families, and schools.

Key points

	• Concussion results from biomechanical forces leading to temporary neurometabolic alterations that reflect a functional disturbance rather than a structural injury.
	• Concussion in children is unique, occurring within the context of neurodevelopment.
	• Core symptoms of concussion in children are similar to adults, including abnormalities in physical, cognitive, emotional, or sleep domains; however, resolution of symptoms is often longer in children.
	• Management of pediatric concussion includes a brief period of physical and cognitive rest of no more than 48 hours. If involved in sports, immediate removal from play is essential followed by a supervised, gradual return to physical activity when cleared by a provider.
	• Assessment and management should be individualized in pediatric concussion.

Historical note and terminology

The term “concussion” is derived from the Latin concutere meaning “to dash together, shake violently,” and the terminology has been noted back to times of Ancient Greece in one short Hippocratic text (105). Current definitions of concussion vary in both literature and practice. Mild traumatic brain injury (mTBI), minor head trauma, closed head injury, and concussion are often used to describe similar constructs, though currently no consensus exists on which one term, or precise definition, to use. In the most recent Consensus Statement on Concussion in Sport 2022, sports-related concussion was defined as:

“A traumatic brain injury caused by a direct blow to the head, neck, or body resulting in an ‘impulsive’ force being transmitted to the brain...This initiates a neurotransmitter and metabolic cascade, with possible axonal injury, blood flow change, and, inflammation affecting the brain. Symptoms and signs may present immediately, or evolve over minutes or hours, and commonly resolve within days, but may be more prolonged.”

The Centers for Disease Control and Prevention (CDC) has developed a website devoted to traumatic brain injury, including concussion in sports (20). This website provides concussion-related educational material, including online concussion training for health care providers and clinical documentation forms (Heads Up and the Acute Concussion Evaluation (ACE) checklist and care plan). This material can be accessed for free at https://www.cdc.gov/heads-up/media/pdfs/providers/ace_v2-a.pdf.

Concussion “grading scales” that attempted to classify concussion severity were previously used, but current pediatric concussion guidelines no longer recommend their use (48). The SCAT6 (Sports Concussion Assessment Tool, version 6, recommended for ages 13 and up) as well as the Child SCAT6 (used for ages 8 to 12) are utilized at most sidelines if there is a concern for a concussion in a player, whereas the Sports Concussion Office Assessment Tool (SCOAT6) has been recommended to provide a standardized and age-appropriate guide to management. These tools utilize Maddocks’ questions as well as the Standardized Assessment of Concussion (SAC) (80; 81; 33). The utility of acute sideline tools, such as the SCAT6 and Child SCAT6, is greatest within the first 72 hours after injury (28). Beyond this window, particularly after 7 days, office-based tools, such as the SCOAT6 and Child SCOAT6, are preferred for structured assessment and follow-up. These instruments emphasize multimodal evaluation of symptoms, cognition, vestibular-ocular function, and balance, providing a more appropriate framework for subacute clinical decision-making. Initial translations, cultural adaptations, and early clinimetric studies of the SCAT6 and Child SCAT6 are emerging (05). However, further validity data across age groups and postinjury time points are still needed. Accordingly, results from these tools should be interpreted with appropriate caution and used as adjuncts to comprehensive clinical assessment.

The management of concussion in young athletes has reached the public health domain, with all 50 states and the District of Columbia passing legislation modeled after the “Zackery Lystedt Law” (Washington State, House Bill 1824, 2009). This legislation mandates the following: concussion education for coaches, athletes, and parents; immediate removal of a child from play if a concussion is suspected; same-day return to play is prohibited; and written clearance from a licensed health care provider for return to play. Many individual states have their own legislation regarding removal from play and return to play that healthcare providers should become familiar with.

Clinical manifestations

Presentation and course

Clinical manifestations of concussion are diverse, and symptoms may emerge within minutes to several days following injury. Commonly reported symptoms across physical, cognitive, emotional, and sleep domains are summarized in Table 1 (70).

Table 1. Common Concussive Symptoms

Physical	Cognitive	Emotional	Sleep
Headache	Feeling mentally foggy	Irritability	Drowsiness
Nausea	Problems concentrating	Sadness	Sleeping more than usual
Fatigue	Problems remembering	Feeling more emotional	Sleeping less than usual
Visual problems	Feeling more slowed down	Nervousness	Trouble falling asleep
Balance problems
Sensitivity to light/noise
Numbness/tingling
Vomiting
Dizziness

In children with concussion presenting to the emergency department, headache, nausea, dizziness, blurry/double vision, and not feeling “sharp” were the most common symptoms and were associated with altered mental status (43). Although physical symptoms are more prominent early after injury, a study indicates that emotional and sleep symptoms are more likely to develop over days to weeks following the injury (35).

Commonly accepted “red flags” that may indicate a more severe brain injury and require further evaluation include focal neurologic signs such as weakness or sensory symptoms, loss of consciousness, excessive symptoms such as severe headache, persistent emesis, confusion lasting longer than 30 minutes, altered mental status, as well as clinical judgment.

Although the core symptoms of concussion are the same among all age groups, it is important to consider the developmental expectations and the communication ability of each child. For example, a 3-year-old may not be able to verbalize “I have a headache, blurry vision, feel tired, and am having difficulty concentrating.” The parent, however, may note that their 3-year-old is acting “more clingy than usual,” “wants to stay inside,” “is not as playful,” etc. A prospective study indicates that compared to school-age children, preschool children are less likely to report concussive symptoms, and symptoms reported were those able to be observed easily by the parent/caregiver (93). They even tend to show more changes in mood and behavior over time (139). A more recent review by Beauchamp and colleagues further emphasizes that infants and preschoolers frequently exhibit nonverbal symptoms of concussion, including altered sleep, feeding changes, increased irritability, and distractibility (08). Because verbal self-report is unreliable in this age group, tools such as observational inventories (eg, REACTIONS) are essential to identify post-concussive symptoms. Notably, symptoms may persist for up to 3 months, even after early physical signs have resolved, highlighting the importance of caregiver education, structured follow-up, and developmentally appropriate monitoring.

Preschool-aged children: monitoring

	• In children younger than 6 years, concussion symptoms are often nonverbal and behaviorally expressed, including changes in sleep, appetite, irritability, clinginess, attention, and play behavior.
	• Standard self-report symptom checklists are unreliable in this age group; assessment should rely on caregiver observations and developmentally appropriate tools, such as:
		-- REACTIONS (Report of Early Childhood Traumatic Injury Observations & Symptoms): validated tools designed to screen for post-concussive behaviors in children 6 months to 8 years (31).
		-- COCO Tools (Concussions in Early Childhood): a toolkit including the Early Childhood Detection Tool and Recovery Tool to help parents and educators recognize subtle symptoms in children under 5 years (08).
		-- Health and Behavior Inventory (HBI): parent-report versions can be used to track observable physical and cognitive changes in younger children (ages 5–12) over time.
	• Although many young children improve within weeks, nonverbal post-concussive symptoms may persist for up to approximately 3 months in some cases, even after early physical signs have resolved.
	• These children require structured follow-up, caregiver education, and gradual return-to-routine activities to confirm full recovery and identify those who need additional support.

Although the role of gender in concussion recovery is unclear, one study suggests female athletes reported more baseline symptoms, greater post-concussion symptom severity, and took longer to return to baseline symptoms after injury (141; 142).

Prognosis and complications

Most evidence indicates more pronounced recovery from symptoms within the first week after the injury (75). Evaluating a large cohort of high school and college athletes over 10 years of age, only 10% reported post-concussive symptoms beyond 7 days (90). However, compared to adults, children and adolescents are more likely to have prolonged recovery with post-concussive symptoms reported for months (121; 138; 07; 123; 27), particularly in those with recent or multiple prior concussions (19; 34).

Chrisman and colleagues reported that after a concussion, 50% of athletes returned to school by 3 days, 50% returned to sport by 13 days, and 50% returned to a baseline level of symptoms by 3 weeks (22). Ledoux and colleagues were able to further describe how 5- to 7-year-old children had the greatest improvement in concussive symptoms in the first week, and 8 to 12 years and 13 to 18 years had the most prominent change in the first 2 weeks (76). Even further delineation, adolescent girls had predominant improvement of symptoms in the first 4 weeks, with less than half of the remaining girls reaching full recovery by 12 weeks.

The utility of symptom report alone as a measure of concussion recovery is questionable, as post-concussive symptoms are not specific to concussion and have been reported in control cohorts such as children with only orthopedic injuries (138; 113). That children without concussions also reporting persistent “post-concussive” symptoms indicates that there are likely factors beyond injury that affect outcome based exclusively on report of symptoms. Evidence also suggests potential recall bias (“the good old days” bias) in the rating of premorbid symptoms, as prospectively obtained parental ratings of their child’s premorbid symptoms decreased 80% from the time of injury to 1 month after the concussion (16). Exaggeration of symptoms may also hinder accuracy of symptom scales as the sole measure of concussion recovery, as several studies suggest a relationship between failing effort testing and increased symptom report in children with concussion (02; 65).

Stratifying risk for persistent post-concussion symptoms has been mostly elusive except for some studies reporting premorbid risk factors, such as school-age children (11), female gender (53), early/initial symptom burden (96; 114), and various acute and subacute symptoms (100; 63). Bernard and colleagues also mentioned that children with neuropsychological ailments such as learning disability and ADHD tend to have longer lasting symptoms (12). The influence of injury-related factors such as loss of consciousness or amnesia on outcome remains unclear (90; 97). However, early concussive symptom severity report has been linked to persistent symptoms (97; 96). Additionally, mechanism of injury may influence recovery. A study of adolescents and young adults presenting to a concussion clinic revealed that those with motor vehicle accidents had more impaired scores on a computerized cognitive battery and a longer course of recovery (118).

Although many children experience substantial improvement within the first several weeks, newer longitudinal data suggest that recovery may be more protracted for a meaningful subset of patients. A 2025 cohort study by Beauchamp and colleagues found that some children and adolescents required 3 months or longer to reach optimal recovery thresholds, particularly those with higher initial symptom burden, female sex, or preexisting comorbidities, such as migraine, ADHD, or mood disorders (08). These findings reinforce the need for individualized prognostic counseling and for continued follow-up in patients at higher risk for persistent symptoms.

In addition to traditional risk factors for prolonged recovery (such as female gender, early symptom burden, and comorbid conditions) emerging evidence points to systemic dysregulation across the autonomic, immune, and endocrine systems as a potential driver of persistent post-concussive symptoms. Pertab and colleagues propose a unifying neurophysiological framework in which concussion destabilizes these regulatory systems, leading to symptoms that resemble other dysautonomia-related conditions (eg, fatigue, dizziness, brain fog, mood disturbance) (107). This model may offer a pathophysiological explanation for why children with seemingly mild injuries can still experience protracted recovery. Early intervention strategies, such as sleep optimization, graded exercise, and behavioral activation targeting homeostatic balance, may help mitigate these effects and promote recovery. Though primarily studied in adults, this framework is relevant in pediatrics given the vulnerability of developing regulatory systems and the increasing interest in biopsychosocial treatment models.

Within acute care settings, there are not yet clear variables or measures that can predict the course of concussive recovery. In a study of 406 children 5 to 18 years old presenting to an emergency department with concussion, 29% reported three or more symptoms rated “worse than before injury” in a telephone interview 3 months after injury. Multivariate analysis of this sample suggests that adolescent age, headache on presentation to the emergency department, and admission to the hospital were predictive of post-concussive syndrome, although premorbid factors were not evaluated in this study (03). In another study of children with concussion presenting to the emergency department, low scores on reaction time or cognitive flexibility obtained from a computerized cognitive battery administered in the emergency department were significantly related to persistent post-concussive symptoms at 1 month, but not to symptoms 2 or 3 months postinjury (15). On initial evaluation in a sports medicine concussion clinic, children with vestibular symptoms took significantly longer to return to both school and sports (26). It is important to gain a better understanding of variables that predict the course of recovery on acute or early evaluation as this could allow time for individualized and optimized management.

Studies also indicate the importance of preinjury child and parent factors in recovery from injury. For instance, McNally and colleagues noted that although injury-specific factors contributed to the report of concussive symptoms early, noninjury-related factors, mostly premorbid symptoms of child and parent adjustment, consistently contributed to post-concussive symptoms (94). Higher parental anxiety and higher child preinjury health-related quality of life predict persistent post-concussive symptoms between 6 and 18 months after injury (103). More significant life stressors have also been linked to persistent post-concussive symptoms in children (122). In a sports medicine concussion clinic, post-concussive symptoms were significantly related to a personal or family history of mood disorder, psychiatric disorders, or migraines (100). The complexity and variability of factors contributing to injury and recovery (premorbid child and family history, mechanism of injury, clinical evaluation and management, and postinjury factors) hinder accurate clinical prognostic ability.

In an adolescent population, females were more likely to report posttraumatic headache and had a longer recovery (14). Symptom management may also contribute to persistent posttraumatic headache. An evaluation of children with chronic posttraumatic headaches revealed that 70% were medication overuse headaches and nearly 70% resolved with discontinuation of over-the-counter pain medications (52).

A particularly concerning potential complication arises when an athlete sustains a second head injury before fully recovering from an initial concussion. In rare cases, this scenario has been associated with catastrophic cerebral edema, often referred to as “second impact syndrome” (or SIS). This phenomenon is thought to occur more frequently in children and adolescents and is associated with poor outcomes, including death, though much of the published evidence remains limited to case reports and small series. The underlying mechanism is believed to involve dysautoregulation of cerebral blood flow, resulting in rapid and diffuse cerebral swelling (50; 51).

Chronic traumatic encephalopathy, a potential sequelae of repetitive brain injuries, is beyond the scope of this discussion.

Clinical vignette

A healthy, athletic 14-year-old girl presented to clinic with her parents after a hit to the head during cheer practice. During a stunt, she was in position as a base holding up another smaller girl, when the smaller girl lost her balance causing her foot to land on top of this patient’s head. There was no loss of consciousness, but she had immediate onset of headache. She did not recall the actual incident, and her next memory was of walking over to the side with her hands on head. As she became more aware, her headaches increased in severity, and she developed dizziness, confusion, blurred vision, and unsteadiness. Her family was called to come pick her up. On the way home, she had emesis and, thus, was brought to a local emergency department. Her head and neck CT scans were reported to be normal. Discharge recommendations included resting and concussion clinic referral.

For the first week, she had daily headaches with trouble remembering simple tasks, difficulty concentrating, and was sleeping through large portions of the day. After being seen by her primary care provider, she was recommended to stay home and rest for 2 days. Her symptoms slowly improved with rest 10 days after her injury, she returned to school where her teachers all reported that she seemed “slower.” She had to take breaks during her classes due to headaches and performed poorly on a test (she is typically a straight A student). She had difficulty thinking clearly and speaking during student council meeting.

She was seen in concussion clinic 3 weeks after her concussion. At that time, she was 2 weeks behind in schoolwork but was able to keep up with her current course load, and, though still symptomatic, she was eager to get back to sports as soon as possible. Her main complaints were headache and feeling “foggy.” Her parents also noted that she was more irritable and emotional than usual. Her general and neurologic exams were normal, except for convergence insufficiency and positive Romberg. She had normal balance testing using the Balance Error Scoring System. Neuropsychological testing Immediate Post-Concussion Assessment Cognitive Test (ImPACT) plus additional psychometric measures were average with slight worsening of symptoms after testing.

A return-to-learn care plan was implemented to support school accommodations, with the goal of helping her complete make-up work within a reasonable timeframe while minimizing the risk of falling further behind. She received physical and vestibular therapy two times a week. Physical activity recommendations included gradual increase from light to moderate levels of activity as tolerated (such as walking or riding a stationary bike). This was evaluated and followed by the physical therapist. She was then transitioned to increase activity under the guidance of the school athletic trainer.

She returned for scheduled follow-up after 2 weeks. At that time, she reported that all of her symptoms had resolved, and her parents felt she was at baseline. School accommodations were removed as she had completed all make-up work. We reviewed the gradual return to play and recommended a minimum of 24 hours at each level of activity. She progressed through each stage symptom-free and was able to begin to join the cheer team in the nationals competition.

Biological basis

Etiology and pathogenesis

Dr. Choe described the pathophysiology as the mechanical injury from the force to the head causing a “disruption of cellular membranes resulting in efflux of intracellular potassium… causing neuronal depolarization” (21). This then stimulates neurotransmitters, specifically glutamate, to be excessively released and bind to N-methyl-D-aspartate (NMDA)-receptors. This action opens K+/Ca2+ channels, causing released extracellular Ca2+ to cause cellular damage (21).

Although sports-related concussions have received a great deal of media attention, from professional athletes to little league sports, it is important to remember that falls, motor vehicle accidents, recreational activities, and other accidental events are among the multitude of other causes of concussions.

One study reviewing pediatric concussions in the emergency department reported that 41% of concussions in 11- to 19-year-old children were “sports-related,” whereas only 8% of concussions in children younger than 11 years old were related to sports (95). Haarbauer-Krupa and associates found similar demographics with their pediatric cohort, with 70% of concussions being sports-related, whereas the age group 0 to 4 years had 18% of their concussions that were sports-related, increasing the proportion with age (46). They even noted that those non-sport related concussions were mostly due to falls, being struck by an object, MVC, and assaults. There is no current evidence to suggest a difference in the pathophysiology, recovery, or management of sports-related concussions and concussions from other mechanisms. However, comparison of cognitive measures in college athletes suggests reduced learning, memory, and speed in those athletes participating in contact sports compared to noncontact sports (87).

The stature and nervous system of children are thought to lead to unique vulnerabilities to concussive injury. Karlin summarizes that children have an immature developing nervous system, larger head-body ratio, thinner cranial bones, larger subarachnoid space, different cerebral blood volume/regulation, weaker neck musculature, and incomplete myelination, and increased skull vault elasticity (60). These factors all likely contribute to the differences in concussion injury and recovery specific to the pediatric population.

Monitoring neural response in a mouse model of mTBI demonstrates that impact initiates a neurometabolic cascade characterized by glutamate release, excitatory receptor activation, and ionic fluxes. These processes drive a period of hypermetabolism despite simultaneous reductions in cerebral blood flow and glucose availability (41). The resulting mismatch creates an energy crisis that is followed by depressed cerebral metabolism. Prolonged calcium elevations further disrupt synaptic connectivity and mitochondrial function, ultimately promoting apoptosis. Although neurochemical changes typically normalize within 10 days in experimental models (40), impairments in long-term potentiation have been observed for weeks after injury, suggesting that cellular recovery may lag neurochemical normalization (117).

In the clinical setting, fluid biomarkers offer a window into these acute processes. Rubenstein and colleagues saw that in adults, elevations of total tau (T-tau) and phosphorylated tau (P-tau) have been documented in serum and CSF within days of concussion and traumatic brain injury (115; 116). Higher tau concentrations generally correlate with acute injury severity, functional disability, and radiographical findings, although their ability to predict long-term neurologic outcomes or the development of chronic traumatic encephalopathy remains limited. More recent longitudinal studies suggest that sustained abnormalities in P-tau and the P-tau:T-tau ratio, rather than isolated acute spikes, may be more informative for outcomes at 6 to 12 months (116). Yet even in these studies, tau accounted for only a modest proportion of variance in recovery, underscoring the complexity of post-traumatic brain injury trajectories (10; 132).

In pediatric head injuries, the story is similar but with important distinctions. Prospective studies have shown that both T-tau and P-tau rise acutely in children after traumatic brain injury, with higher levels often associated with more severe injuries and, in some cases, worse outcomes at follow-up (124; 102). These elevations can be detected within hours of injury and may persist for 24 to 48 hours. Some discriminatory capacity has been noted between moderate and severe traumatic brain injury, though findings are inconsistent in cases of uncomplicated sport-related concussion. Several adolescent cohorts have shown no significant changes in plasma tau compared with baseline following mild injuries (133). Such variability likely reflects both the heterogeneity of pediatric concussion and the timing of biomarker sampling. Therefore, the most recent CDC guidelines emphasize that tau and related biomarkers should not be used for the clinical diagnosis of mild traumatic brain injury in children outside of research protocols (78).

Using MRI to compare 12 children with sports-related concussion to controls, cerebral blood flow was significantly altered out to 30 days postinjury (85), which is consistent with prior data of cerebral blood flow dysregulation after brain injury. Magnetic resonance spectroscopy (MRS) imaging revealed altered N-acetylaspartate levels normalizing over 30 days following concussion in adolescent and young adult athletes (129). Furthermore, multiple concussions have been related to alterations in MRS findings (58). SPECT imaging revealed medial temporal hypoperfusion, which significantly correlated with persistent post-concussive symptoms 3 months after injury (01).

Diffusion tensor imaging detected significant white matter tract injuries (suggesting cytotoxic edema) that correlated with post-concussive symptoms (135). White matter alterations have also been linked to clinical concussion assessments in adolescent athletes (131). In a small sample of children with concussion, diffusion abnormalities were able to classify pediatric concussion with 90% accuracy, and diffusion abnormalities persisted at least 4 months after injury (86). Early white matter diffusion alterations were reported in youth with concussion who underwent neuroimaging within 96 hours of injury; however, these changes were not related to acute post-concussive symptoms (04). These studies of post-concussive white matter restricted diffusion suggest cytotoxic edema (such as from axonal swelling) following concussion in children. Furthermore, swine models of mTBI also indicate diffuse axonal injury, the extent of which varied by the plane of induced rotational injury (18).

Compared to a control population, changes in fMRI signal in adolescents with concussion has been related to specific task performance as well as cognitive function and symptom report (49; 61).

Toledo and colleagues thoroughly summarized the current literature on neuroimaging and pathophysiology specific to the developing brain (128).

Serum astrocytic protein S100B and associated autoantibodies have been linked to the number of subconcussive impacts in college football players, suggesting blood–brain barrier disruption; importantly, S100B autoantibody levels were also associated with diffusion tensor imaging abnormalities and cognitive deficits (84). Glial fibrillary acidic protein (GFAP) has similarly emerged as a candidate biomarker, with concentrations at the time of concussion correlating with symptom burden both acutely and at 1-month follow-up (82). Multicenter investigations from Jalali and colleagues demonstrate that GFAP, alone or in combination with UCH-L1 (ubiquitin carboxyl-terminal hydrolase-L1), shows promising sensitivity for detecting clinically important traumatic brain injury in children, raising the possibility that these assays could help reduce unnecessary neuroimaging in the future (57). Despite these encouraging findings, pediatric data remain limited, and professional guidelines (including the 2024 ACEP clinical policy) currently endorse biomarker use only for adult patients. Until further pediatric-specific validation and regulatory approval are achieved, biomarker testing in children should be considered investigational and adjunctive rather than diagnostic (109).

Genetic and other metabolic biomarkers from serum, salivary, cerebrospinal fluid as well as neuroimaging and electrophysiological measures are still experimental.

Epidemiology

The CDC reports 2.8 million traumatic brain injuries annually, 75% of which are mild traumatic brain injury or concussion (126). However, an accurate estimate is difficult to obtain as many concussions are not diagnosed, occur across a wide range of activities, and may be evaluated/diagnosed in multiple locations, including the emergency room or in outpatient settings such as the pediatrician, a sports medicine physician, a pediatric neurologist, or an athletic trainer. Across the spectrum of traumatic brain injury-related injuries, very young children aged 0 to 4 years old had the highest rate of traumatic brain injury-related emergency department visits followed by older adolescents aged 15 to 19 years of age. In 2019, Yaramothu and colleagues reported that pediatric patients who were in organized sport accounted for 53.3% of concussions (137). Within the school setting, soccer has the highest incidence of concussion at 16.5%. The traumatic brain injury rate is higher overall for males of all age ranges; however, in gender-comparable high school sports, a study indicated girls have a higher rate of concussions (83).

It is estimated that concussion is diagnosed in one of every 160 pediatric patients seen in the emergency department, with 60% having head CT and nearly half receiving medical intervention including pain management or intravenous fluids (24). A review of pediatric concussions in organized team sports noted that the number of emergency department visits had doubled for children 8 to 13 years old and increased by more than 200% for 14- to 19-year-old athletes (06).

Evaluating 20 high school sports, the overall concussion rate was 2.5 per 10,000 athletic exposures; the majority of concussions occurred in football, girls’ soccer, wrestling, and basketball (83). Concussion occurred as the largest percentage of injuries sustained within ice hockey. The risk of sustaining a concussion was higher in competition than in practice, with the majority missing more than 1 week of sports due to the concussion. Incidence rate of concussions in 8- to 12-year-olds playing youth football was reported as 1.76 concussions per 1000 athletic exposures; additionally, the risk of concussion was higher in games, compared to practice, and in the 11- to 12-year-old age group compared to 8- to 10-year-old children (66).

In 2019, Kerr and colleagues reported that The National Federation of State High School Associations had indicated a steady rise in high school sports participation overall (a 3.5% increase from 2012–2013 to 2017–2018) (62). When evaluating 20 high school sports, they also reported the overall concussion rate was 4.17 per 10,000 athletic exposures: the majority in boys’ football, followed by girls’ soccer and boys’ ice hockey. The risk of sustaining a concussion was higher in competition than practice. When examining concussion incidence in practice, the highest rates were observed in boys’ football, followed by cheerleading and boys’ wrestling.

In a prospective cohort study conducted from 2016 to 2017 in a youth football league (ages 5–14), Chrisman and colleagues found an athlete-level incidence of 5.1% per season with two-thirds of the concussions occurring during games. This is slightly higher than previously reported in 2013 by Kontos and colleagues but may be due to more surveillance at games. Youth with a history of concussion had a 2-fold increased risk for sustaining an incident concussion, and youth with depression had a 5-fold increased risk of concussion.

A study also showed that children with ADHD are significantly more likely to report a history of concussion compared to children without ADHD (56).

Prevention

Despite increasing knowledge about the risks of concussion unique to children, there is not specific equipment that can prevent a concussion. In fact, evidence suggests the incidence of sports-related concussion was not related to the brand or helmet worn by high school athletes (09; 92). It is important to use safety equipment, from seatbelts in cars to helmets when skiing or biking to protective gear in athletics. There has been discussion about other measures to further protect children in sports, such as a limit on the amount of contact in football practice or the number of “headings” in soccer (similar to a pitch count in baseball). Impact monitoring systems in football helmets have not yet been proven to be clinically efficacious as current studies have not supported the reliability and clinical usefulness of head impact telemetry systems (44; 45). Although not correlated clinically, impact monitoring in youth football reveals an average of 247 notable impacts per season and indicated limiting contact in practice may reduce these exposures (23). Proper technique of high-risk activities, such as tackling, should be taught and emphasized. For sports-related concussions, it is even recommended that athletic trainers use socioecological framework to develop strategies to help mitigate risk for their athletes, which would go beyond watching educational videos or reading handouts (112).

Most importantly, however, is to remove any child displaying symptoms of a concussion from play for more thorough, concussion-specific evaluation. It is important to have children seen and cleared by professionals trained in management of concussion as this should help prevent risk of repeated injury while still recovering from an initial injury.

Diagnostic workup

The latest 6th International Consensus Statement on Concussion in Sport provided updated framework for acute sport-related concussion evaluations within the first 72 hours and up to 1 week after the injury by using Concussion Recognition Tool-6 (CRT6), Sport Concussion Assessment Tool-6 (SCAT6), and Child SCAT6 (104). A systematic review stated that utilizing a combination of computerized cognitive testing and use of the Post-Concussion Symptoms Scale distinguished high school athletes with mild traumatic brain injury from those without traumatic brain injury within the first 4 days of injury, and the Graded Symptom Checklist was found useful in distinguishing children 6 years and older with mild traumatic brain injury from those without within the first 2 days post-injury (78). Additional measures available for immediate assessment of concussion include the Standardized Assessment of Concussion (SAC), King-Devick Test, and balance testing such as the Balance Error Scoring System. There are multiple “apps” on concussion that can be used at the sideline. Independent of the sideline test results, if a child is complaining of symptoms of concussion after an injury, the child should not return to play that day and should be further evaluated.

The selection of concussion assessment tools should be guided by time from injury. The SCAT6 and Child SCAT6 are most useful for acute evaluations within the first 72 hours, when they can assist with sideline or early clinical triage. After this early window, particularly beyond 7 days postinjury, the sensitivity and specificity of SCAT-based measures decline as symptom patterns evolve. For subacute and follow-up assessments, the SCOAT6 and Child SCOAT6 are preferred, as these office-based instruments provide a more comprehensive, multimodal evaluation of symptoms, cognition, vestibular-ocular function, and balance. Using tools appropriate to the postinjury time frame improves clinical decision-making and reduces the risk of misclassification.

Many children are brought to the emergency department for evaluation after concussive injury, leading to critical evaluation of clinical indications to obtain a head CT balanced with the risk of radiation exposure. Over a 5-year period, the rate of head CT use in the evaluation of patients diagnosed with concussion increased nearly 40% despite an overall decrease in head injury severity (140). One hospital found that creating and implementing a “minor head injury guideline” led to a reduced number of head CTs (42). In an effort to avoid unnecessary head CTs, the Pediatric Emergency Care Applied Research Network (PECARN) derived and validated two age-based prediction rules to identify children at very low risk of clinically important traumatic brain injuries who do not typically require CT scans (68). Up to 7.5% of children seen in the emergency department with mild traumatic brain injury will have an intracranial injury. It is recommended that health care professionals should not routinely obtain head CT for diagnostic purposes in mild traumatic brain injury. They should, however, identify risk factors that may indicate a more severe form of traumatic brain injury and, thus, warrant neuroimaging. These include age younger than 2 years, vomiting, loss of consciousness, severe mechanism of injury, severe or worsening headache, amnesia, nonfrontal scalp hematoma, GSC lower than 15, and clinical suspicion for a skull fracture (78).

Serum biomarkers, such as glial fibrillary acidic protein (GFAP) and ubiquitin C-terminal hydrolase-L1 (UCH-L1), have shown promise for identifying clinically important traumatic brain injury and for reducing unnecessary head CT use. Multicenter pediatric studies (2024–2025) have demonstrated high sensitivity of GFAP, alone or in combination with UCH-L1, for detecting intracranial injury after head trauma (57). Despite these encouraging data, current FDA clearance and U.S. guideline endorsements apply only to adults, and routine pediatric use remains investigational. At present, biomarker testing in children should be considered adjunctive and research-stage, not a replacement for clinical assessment and established imaging decision rules. There are computerized tools available for assessment of cognitive function after an injury. These computerized tools, such as ImPACT, are increasingly being used in athletics to collect baseline data, although the clinical utility of baseline testing has not been fully established. Evidence indicates that the validity of computerized tests used for baseline (preinjury) documentation may be affected by multiple factors, including age, test setting, and recent sleep (77; 88). The lower age limit of ImPACT is 12 years old, and a pediatric version of ImpACT is also now available for 5 to 11 years of age. Taylor provides a summary and critical assessment of neuropsychological measures used in pediatric concussion (125).

More research is needed to validate all of the acute and computerized testing in the pediatric concussion population. All of these tests may also be influenced by premorbid factors such as underlying ADHD as well as use of stimulants; thus, interpretation is often appropriately deferred to a pediatric neuropsychologist. In fact, emerging evidence indicates the confounding effects of ADHD and learning disability on current concussion testing and supports evaluation of different baseline/normalized scores for those with premorbid learning and attention disorders (36). Additional “pencil and paper” tests or other tools may be appropriately used by neuropsychologists when evaluating children with concussion.

Graded exercise testing, vestibular-ocular motor screening, and dual task balance testing are some of the additional methods being explored to aid the assessment of concussion (55; 74; 101).

Management

More evidence is needed regarding potential acute interventions before changes are expected in the management shortly after concussion. However, for those seeking emergent or urgent care, concussion education and discharge instructions are critical. Patients and families should be counseled that most (70% to 80%) of children with mild traumatic brain injury do not show significant difficulties that last more than 1 to 3 months and that each injury is unique and follows its own healing trajectory. It Is important to recognize premorbid conditions that will assist in anticipatory guidance for prognosis as well. These include a previous history of concussions, lower cognitive ability, neurologic or psychological disorders, learning disabilities, increased pre-injury symptoms, and family or social stressors (78).

An analysis of concussion in one pediatric emergency department indicated that most children with concussion were discharged without a concussion diagnosis or instructions and restrictions (30). A survey of pediatric emergency care providers revealed that 81% of providers report using a published concussion guideline for clinical management and 91% reported using medications to treat concussive symptoms, most often acetaminophen and nonsteroidal anti-inflammatory treatment (64).

Early education on concussion symptoms, expected course of recovery, and management/coping strategies may notably improve recovery. One study found that parents and children seen in clinic within 1 week from injury and given a basic concussion information booklet demonstrated recovery within 3 months compared to the control group of children with concussion (not given the pamphlet and seen at 3 months) who reported more symptoms and increased stress 3 months after injury (108).

Hallmarks in the management of pediatric concussion include immediate removal from the game at onset of concussive symptoms and NO same day return to play. Physical and cognitive rest is recommended while actively symptomatic in the acute period; however, neither evidence nor guidelines exist to clarify the definition or extent of either. Silverberg and Iverson provide a thoughtful analysis of the current concussion management recommendations for physical and cognitive rest (120).

Based on the neurometabolic case in mouse models of mTBI, the occurrence of diffuse brain edema following a second injury before recovery from an initial concussion, and a window of neurometabolic vulnerability between concussions noted in MRS studies (130) and mouse models (98), there seems to be a period where the brain is uniquely susceptible. Thus, “rest” is a reasonable recommendation after concussion. At this time, the precise timing of vulnerability in children with concussion has not been further detailed. Additionally, the meaning of “rest” is unclear, though certainly avoiding a second injury during the acute phase is critical.

Cognitive and physical rest. Clinical treatment plans often include extending “rest” until the patient is fully asymptomatic. However, De Luigi and colleagues reviewed a compilation of studies that compared and contrasted rest, exercise, rehabilitation, and return to activity in actively symptomatic pediatric concussion patients, and it was found that there was strong evidence to suggest sub-symptom threshold aerobic exercise (such as walking or stationary bike) was beneficial for adolescent patients regarding their concussion symptoms (29). The term “relative rest” is more appropriate in regard to recommendations for continuing activities of daily living and reduced screen time in the first 48 hours (104). Sleep disturbances are common across pediatric age groups following concussion and may contribute to symptom persistence. Sleep hygiene counseling should be part of routine follow-up (08; 107). Although initial restriction of screen time in the first 48 hours may reduce symptom burden, prolonged restriction beyond this period has not shown added benefit and may contribute to social withdrawal or anxiety (79).

Return-to-learn. “Cognitive rest” was once widely recommended during the acute phase (first few days) following concussion. However, current guidance from the American Academy of Pediatrics (AAP) and the CDC HEADS UP program (2024–2025) emphasizes an early, supported return to school rather than prolonged cognitive restriction. Evidence now supports the benefits of returning to academic activities within 24 to 48 hours with appropriate accommodations (110). A retrospective review found that prescribing extended cognitive rest did not shorten recovery time; instead, the number of acute symptoms was the strongest predictor of prolonged recovery (39). In one study, children and adolescents assigned to 5 days of strict rest reported more symptoms and experienced longer recovery compared with peers who rested for only 1 to 2 days before gradually resuming activities (127). More recent reviews continue to support a brief initial rest period of 24 to 48 hours, followed by a symptom-guided return to cognitive and physical activity (104; 13). Other research suggests that both high total symptom burden and excessive early cognitive exertion may lengthen recovery, particularly in children engaging in demanding academic tasks too soon after injury (17). Academic performance can also be negatively affected in children who have not yet fully recovered (111). Consistent with CDC recommendations, screen time moderation during the first 48 hours is reasonable; a randomized controlled trial demonstrated that limiting recreational screen use in this initial period shortens time to symptom resolution, whereas prolonged restriction beyond 48 hours provides no added benefit (79). The Concussion in Sport Group and CDC both endorse a structured, stepwise “Return-to-Learn” approach that promotes early school re-engagement with individualized supports (104; 99; 20).

Return-to-learn protocols are a critical component of pediatric concussion management, given the academic demands and cognitive vulnerability of school-aged children. A systematic review evaluated 21 studies involving 8475 athletes aged 5 to 27 years and found substantial variability in return-to-learn timelines and definitions. The median time to any school return was 5 days, with full academic reintegration occurring at a median of 17.5 days. Notably, female sex and higher initial symptom burden were associated with longer return-to-learn duration. These findings emphasize the need for individualized, symptom-guided return-to-learn plans that facilitate early cognitive re-engagement while minimizing symptom exacerbation and academic disruption (13). Therefore, most students can return to school within 1 to 2 days with accommodations; brief (< 48 hours) screen time moderation can reduce symptom duration, but extended restriction has no added benefit. Return-to-learn plans should be individualized and symptom-guided. Common academic accommodations include shortened school days, rest breaks, reduced workload, extended time for assignments and tests, and modification of screen-based activities as needed (20; 119). As symptoms improve, supports should be gradually removed, with the goal of full academic participation prior to unrestricted return to sports and other high-risk activities. These return-to-learn recommendations reflect current CDC HEADS UP guidance (2024–2025) and AAP evidence reviews, which emphasize early school re-engagement with individualized academic supports.

Return-to-play. Physical rest after concussion is equally nuanced. Current evidence supports early, symptom-limited physical activity rather than prolonged inactivity. After an initial 24 to 48 hours of relative rest, children and adolescents should begin individualized, sub-symptom threshold aerobic exercise within 7 to 10 days of injury when symptoms are mild or transient. A randomized clinical trial demonstrated that early initiation of controlled aerobic activity significantly shortens overall recovery time and reduces the risk of persistent post-concussive symptoms compared with strict rest alone (72).

More recent studies and syntheses confirm that early, individualized sub-symptom aerobic exercise not only promotes symptom resolution but also supports cognitive and executive function recovery. Structured aerobic activity initiated within 7 to 10 days has been associated with faster improvements in attention, processing speed, and working memory, along with better autonomic regulation and mood (72). These benefits are achieved when exercise is prescribed below the symptom threshold and progressed gradually, reinforcing early active rehabilitation as a therapeutic cornerstone of pediatric concussion care.

Prior investigations likewise support graded exercise during the subacute period (37; 73), which may facilitate recovery of post-injury cerebral blood flow regulation (71). Importantly, a prolonged symptom-free waiting period, such as delaying activity for several days after symptoms resolve, does not appear to improve outcomes compared with earlier reintroduction of activity (89). In a cohort of children and adolescents presenting to a sports medicine clinic, higher levels of daily physical activity after injury were associated with shorter symptom duration, suggesting that appropriately dosed exertion is not harmful and may be beneficial (54).

Accordingly, once early sub-symptom exercise is tolerated, progression through a structured return-to-play framework is recommended. Following CDC HEADS UP guidance (2024-2025), athletes should advance through a 6-step graduated return-to-play progression, with at least 24 hours at each stage and no same-day return to sport. An individualized rehabilitation program that uses graded aerobic testing to determine submaximal thresholds can assist in guiding safe advancement (25).

Management considerations for infants and preschool-aged children. Given the high potential for prolonged symptoms, clinical providers may also notice deconditioning or mood effects (often leading to a late increase in symptoms) if a child is withheld from all physical activity until asymptomatic. One small resting state–fMRI indicated altered connections present only after physical exertion 10 days after injury (59), and another study of adolescent athletes demonstrated decline in memory testing and speed on ImPACT after physical exertion (91). Thus, the specific timing, duration, and intensity of gradual exercise represent another area in need of evidence.

Rehabilitation and exercise therapy. Gradual return to play is recommended under the guidance of a trainer, coach, physician, or other provider skilled in managing concussions. A child should complete each level of activity for a minimum of 24 hours before advancing; thus, it should take a minimum of 6 days before returning to full contact sports. The American Academy of Pediatrics report on sports-related concussion in adolescents and children provides another sample of the stepwise approach to resuming physical activity (47). It is important to assure a child has resumed and is tolerating their full school load (the “job” of a child) prior to complete clearance for sports. The CDC and Concussion in Sport Group have published guidelines on “Return to Sport” strategy (104). This graduated approach is consistent with the CDC HEADS UP 2024–2025 return-to-sport framework and the AAP’s 2023 recommendations supporting early, symptom-limited aerobic activity as part of active concussion rehabilitation.

The following are Gradual Return to Play guidelines as per the ACE Care Plan:

	1. No physical activity.
	2. Low levels of physical activity. This includes walking, light jogging, light stationary biking, and light weightlifting (lower weight, higher reps, no bench, no squat).
	3. Moderate levels of physical activity with body or head movement. This includes moderate jogging, brief running, moderate-intensity stationary biking, moderate-intensity weightlifting (reduced time or reduced weight from the typical routine).
	4. Heavy noncontact physical activity. This includes sprinting or running, high-intensity stationary biking, regular weightlifting routine, noncontact sport-specific drills (in three planes of movement).
	5. Full contact in controlled practice.
	6. Full contact in game play.

Accommodations involve communication with the school guidance counselor, administrator, nurse, or athletic trainer, if available. The ACE Care Plan provided by the CDC includes a template for both school and physical accommodations. It is also important to assess tolerance/symptom exacerbation and remove/adjust supports as needed. The treatment plan should be individualized to each specific child.

Management of concussion in early childhood requires developmentally sensitive approaches that rely heavily on caregiver observation and structured follow-up. Beauchamp and colleagues emphasize that unlike older children, infants and preschoolers cannot reliably report internal symptoms, so monitoring must focus on observable behaviors—such as changes in sleep, appetite, mood, or play (08). Structured follow-up is essential to assess symptom resolution and emerging developmental concerns, particularly in domains like attention, emotional regulation, and language. Families benefit from clear anticipatory guidance, including reassurance about typical recovery trajectories and recommendations for gradually resuming normal activities. However, persistent behavioral concerns or developmental regression should prompt referral to a pediatric concussion specialist, neuropsychologist, or developmental pediatrician.

Posttraumatic headache was reported in almost 8% of children 3 months after having sustained a concussion, with 82% having past or family medical history of migraines (67). Larsen and colleagues performed a systematic review of pharmacologic treatment of acute and persistent posttraumatic headaches, and they concluded that there is minimal evidence with an increased need for randomized control trials to draw better conclusions (69). Regarding which medications are typically used, there was a survey of 95 child neurologists who manage posttraumatic headache. Amitriptyline/nortriptyline was chosen as a first-line agent 94% of the time, followed by topiramate at 72% and vitamins/supplements at 59%. Nonsteroidal anti-inflammatory medications were most recommended as abortive treatment (106). Caution should be taken to avoid medication overuse headaches, especially with nonsteroidal anti-inflammatory medications. Proper nutrition, adequate hydration, and rest are strongly encouraged. Docosahexaenoic acid is felt to be beneficial for overall brain health, and there is emerging evidence of the protective role of docosahexaenoic acid in injured brain (136); however, effective or treatment doses specific to children have not been clearly established.

It is important to consider a multidisciplinary approach for children. Early evidence suggests that an active rehabilitation program can promote recovery with reduced symptoms, decreased fatigue, and improved mood for adolescents slow to recover from a sports-related concussion (38).

Physical therapy can provide endurance training and encourage return to physical activity for children who remain persistently inactive. There was a case control study that evaluated benign paroxysmal positional vertigo in concussed pediatric patients occurring in about one third of their patients. All of their patients with benign paroxysmal positional vertigo were able to be treated with repositioning maneuvers (134). This further stresses the need of physical therapy for patients, even in the acute period.

Screening for concomitant mental health concerns or other stressors are important. Behavioral psychology can work on headache management techniques or cognitive behavior therapy in certain circumstances.

Outcomes

Most evidence indicates gradual recovery from symptoms within days to weeks of injury. Compared to adults, children and adolescents are more likely to have prolonged recovery with post-concussive symptoms reported for months in only a minority (121; 138; 07; 123; 27).

Patients and families should be counseled that most (70% to 80%) of children with mild traumatic brain injury do not show significant difficulties that last more than 1 to 3 months and that each injury is unique and follows its own healing trajectory (78). Chrisman and colleagues reported that after a concussion, 50% of athletes returned to school by 3 days, 50% returned to sport by 13 days, and 50% returned to a baseline level of symptoms by 3 weeks (22).

References

01: Agrawal D, Gowda NK, Bal CS, Pant M, Mahapatra AK. Is medial temporal injury responsible for pediatric postconcussion syndrome. A prospective controlled study with single-photon emission computerized tomography. J Neurosurg 2005;102(2 Suppl):167-71. PMID 16156226
02: Araujo GC, Antonini TN, Monahan K, et al. The relationship between suboptimal effort and postconcussion symptoms in children and adolescents with mild traumatic brain injury. Clin Neuropsychol 2014;28(5):786-801. PMID 24646066
03: Babcock L, Byczkowski T, Wade SL, Ho M, Mookerjee S, Bazarian JJ. Predicting postconcussion syndrome after mild traumatic brain injury in children and adolescents who present to the emergency department. JAMA Pediatr 2013;167(2):156-61. PMID 23247384
04: Babcock L, Yuan W, Leach J, Nash T, Wade S. White matter alterations in youth with acute mild traumatic brain injury. J Pediatr Rehabil Med 2015;8(4):285-96. PMID 26684069
05: Baioccato V, Bazo M, Leo I, et al. Translation, cultural adaptation, and validation of the Concussion Recognition Tool 6 (CRT6™), Sport Concussion Assessment Tool 6 (SCAT6?) and Sport Concussion Office Assessment Tool 6 (SCOAT6™): the Italian process. Ital J Pediatr 2025;51(1):109. PMID 40197289
06: Bakhos LL, Lockhart GR, Myers R, Linakis JG. Emergency department visits for concussion in young child athletes. Pediatrics 2010;126(3):e550-6. PMID 20805145
07: Barlow KM, Crawford S, Stevenson A, Sandhu SS, Belanger F, Dewey D. Epidemiology of postconcussion syndrome in pediatric mild traumatic brain injury. Pediatrics 2010;126(2):e374-81. PMID 20660554
08: Beauchamp MH, Anderson V, Ewing-Cobbs L, et al. Early childhood concussion. Pediatrics 2024;154(5):e2023065484. PMID 39380506
09: Benson BW, McIntosh AS, Maddocks D, Herring SA, Raftery M, Dvorák J. What are the most effective risk-reduction strategies in sport concussion? Br J Sports Med 2013;47(5):321-6. PMID 23479492
10: Bergauer A, van Osch R, van Elferen S, Gyllvik S, Venkatesh H, Schreiber R. The diagnostic potential of fluid and imaging biomarkers in chronic traumatic encephalopathy (CTE). Biomed Pharmacother 2022;146:112602. PMID 35062068
11: Bernard CO, Ponsford JA, McKinlay A, McKenzie D, Krieser D. Predictors of post-concussive symptoms in young children: injury versus non-injury related factors. J Int Neuropsychol Soc 2016;22(8):793-803. PMID 27619107
12: Bernard CO, McKinlay A, Krieser D, Ponsford JL. Postconcussive symptoms following mild TBI and extracranial injury: what are the contributing factors? J Int Neuropsychol Soc 2020;26(5):451-63. PMID 31822313
13: Bishay AE, Jallow O, Jo J, et al. Return-to-learn following sport-related concussion: a systematic review. J Neurosurg Pediatr 2025;36(2):173-85. PMID 40344757
14: Bramley H, Heverley S, Lewis MM, Kong L, Rivera R, Silvis M. Demographics and treatment of adolescent posttraumatic headache in a regional concussion clinic. Pediatr Neurol 2015;52(5):493-8. PMID 25728223
15: Brooks BL, Daya H, Khan S, Carlson HL, Mikrogianakis A, Barlow KM. Cognition in the emergency department as a predictor of recovery after mild traumatic brain injury. J Int Neuropsychol Soc 2016;22(4):379-87. PMID 26786357
16: Brooks BL, Kadoura B, Turley B, Crawford S, Mikrogianakis A, Barlow KM. Perception of recovery after pediatric mild traumatic brain injury is influences by the “good old days” bias: tangible implications for clinical practice and outcomes research. Arch Clin Neuropsychol 2014;29(2):186-93. PMID 24196003
17: Brown NJ, Mannix RC, O’Brien MJ, Gostine D, Collins MW, Meehan WP 3rd. Effect of cognitive activity level on duration of post-concussion symptoms. Pediatrics 2014;133(2):e299-304. PMID 24394679
18: Browne KD, Chen XH, Meaney DF, Smith DH. Mild traumatic brain injury and diffuse axonal injury in swine. J Neurotrauma 2011;28(9):1747-55. PMID 21740133
19: Castile L, Collins CL, McIlvain NM, Comstock RD. The epidemiology of new versus recurrent sports concussions among high school athletes, 2005-2010. Br J Sports Med 2012;46(8):603-10. PMID 22144000
20: Centers for Disease Control and Prevention. Returning to school after a concussion. Available at: CDC HEADS UP. Accessed 2025.
21: Choe MC. The pathophysiology of concussion. Curr Pain Headache Rep 2016;20(6):42. PMID 27184060
22: Chrisman SPD, Lowry S, Herring SA, et al. Concussion incidence, duration, and return to school and sport in 5- to 14-year-old American football athletes. J Pediatr 2019;207:176-84. PMID 30554790
23: Cobb BR, Urban JE, Davenport EM, et al. Head impact exposure in youth football: elementary school ages 9-12 years and the effect of practice structure. Ann Biomed Eng 2013;41(12):2463-73. PMID 23881111
24: Colvin JD, Thurm C, Pate BM, Newland JG, Hall M, Meehan WP 3rd. Diagnosis and acute management of patients with concussion at children’s hospitals. Arch Dis Child 2013;98(12):934-8. PMID 23852997
25: Cordingley D, Girardin R, Reimer K, et al. Graded aerobic treadmill testing in pediatric sports-related concussion: safety, clinical use, and patient outcomes. J Neurosurg Pediatr 2016;25(6):693-702. PMID 27620871
26: Corwin DJ, Wiebe DJ, Zonfrillo MR, et al. Vestibular deficits following youth concussion. J Pediatr 2015;166(5):1221-5. PMID 25748568
27: Corwin DJ, Zonfrillo MR, Master CL, et al. Characteristics of prolonged concussion recovery in a pediatric subspecialty referral population. J Pediatr 2014;165(6):1207-15. PMID 25262302
28: Davis GA, Schneider KJ, Anderson V, et al. Pediatric sport-related concussion: recommendations from the Amsterdam Consensus Statement 2023. Pediatrics 2024;153(1):e2023063489. PMID 38044802
29: De Luigi AJ, Bell KR, Bramhall JP, et al. Consensus statement: An evidence-based review of exercise, rehabilitation, rest, and return to activity protocols for the treatment of concussion and mild traumatic brain injury. PM R 2023;15(12):1605-42. PMID 37794736
30: De Maio VJ, Joseph DO, Tibbo-Valeriote H, et al. Variability in discharge instructions and activity restrictions for patients in a children’s ED postconcussion. Pediatr Emer Care 2014;30(1):20-5. PMID 24365726
31: Dupont D, Beaudoin C, Desire N, Tran M, Gagnon I, Beauchamp MH. Report of early childhood traumatic injury observations & symptoms: preliminary validation of an observational measure of postconcussive symptoms. J Head Trauma Rehabil 2002;37(2):E102-12. PMID 33935228
32: Dupont D, Tang K, Beaudoin C, et al. Postconcussive symptoms after early childhood concussion. JAMA Netw Open 2024;7(3):e243182. PMID 38512252
33: Echemendia RJ, Brett BL, Broglio S, et al. Sport concussion assessment tool- 6 (SCAT6). Br J Sports Med 2023;57(11):622-31. PMID 37316203
34: Eisenberg MA, Andrea J, Meehan W, Mannix R. Time interval between concussions and symptom duration. Pediatrics 2013;132(1):8-17. PMID 23753087
35: Eisenberg MA, Meehan WP 3rd, Mannix R. Duration and course of post-concussive symptoms. Pediatrics 2014;133(6):999-1006. PMID 24819569
36: Elbin RJ, Kontos AP, Kegel N, Johnson E, Burkhart S, Schatz P. Individual and combined effects of LD and ADHD on computerized neurocognitive concussion test performance: evidence for separate norms. Arch Clin Neuropsychol 2013;28(5):476-84. PMID 23608188
37: Gagnon I, Galli C, Friedman D, Grilli L, Iverson GL. Active rehabilitation for children who are slow to recover following sport-related concussion. Brain Inj 2009;23(12):956-64. PMID 19831492
38: Gagnon I, Grilli L, Friedman D, Iverson GL. A pilot study of active rehabilitation for adolescents who are slow to recover from sport-related concussion. Scand J Med Sci Sports 2016;26(3):299-306. PMID 25735821
39: Gibson S, Nigrovic LE, O'Brien M, Meehan WP 3rd. The effect of recommending cognitive rest on recovery from sport-related concussion. Brain Inj 2013;27(7-8):839-42. PMID 23758286
40: Giza CC, Hovda DA. Ionic and metabolic consequences of concussion. In: Cantu RC, Cantu RI. Neurologic Athletic and Spine Injuries. St Louis, MO: WB Saunders Co, 2000:80-100.
41: Giza CC, Hovda DA. The Neurometabolic Cascade of Concussion. J Athl Train 2001;36(3):228-235. PMID 12937489
42: Goldberg J, McClaine RJ, Cook B, et al. Use of a mild traumatic brain injury guideline to reduce inpatient hospital imaging and charges. J Pediatr Surg 2011;46(9):1777-83. PMID 21929989
43: Grubenhoff JA, Kirkwood MW, Deakyne S, Wathen J. Detailed concussion symptom analysis in a paediatric ED population. Brain Inj 2011;25(10):943-9. PMID 21749192
44: Guskiewicz KM, Mihalik JP, Shankar V, et al. Measurement of head impacts in collegiate football players: relationship between head impact biomechanics and acute clinical outcome after concussion. Neurosurgery 2007;61(6):1244-52. PMID 18162904
45: Gysland SM, Mihalik JP, Register-Mihalik JK, Trulock SC, Shields EW, Guskiewicz KM. The relationship between subconcussive impacts and concussion history on clinical measures of neurologic function in collegiate football players. Ann Biomed Eng 2012;40(1):14-22. PMID 21994067
46: Haarbauer-Krupa J, Arbogast KB, Metzger KB, et al. Variations in mechanisms of injury for children with concussion. J Pediatr 2018;197:241-248.e1. PMID 29627189
47: Halstead ME, Walter KD; Council on Sports Medicine and Fitness. American Academy of Pediatrics. Clinical report--sport-related concussion in children and adolescents. Pediatrics 2010;126(3):597-615. PMID 20805152
48: Halstead ME, Walter KD, Moffatt K. Sport-related concussion in children and adolescents. Pediatrics 2018;142(6):e20183074. PMID 30420472
49: Hammeke TA, McCrea M, Coats SM, et al. Acute and subacute changes in neural activation during the recovery from sport-related concussion. J Int Neuropsychol Soc 2013;19(8):863-72. PMID 23829951
50: Herring S, Kibler WB, Putukian M, et al. Selected issues in sport-related concussion (SRC | mild traumatic brain injury) for the team physician: a consensus statement. Br J Sports Med 2021a;55(22):1251-61. PMID 34134974
51: Herring S, Kibler WB, Putukian M, et al. Selected issues in sport-related concussion (SRC | mild traumatic brain injury) for the team physician: a consensus statement. Curr Sports Med Rep 2021b;20(8):420-31. PMID 34357889
52: Heyer GL, Idris SA. Does analgesic overuse contribute to chronic post-traumatic headaches in adolescent concussion patients? Pediatr Neurol 2014;50(5):464-8. PMID 24656666
53: Heyer GL, Young JA, Rose SC, McNally KA, Fischer AN. Post-traumatic headaches correlate with migraine symptoms in youth with concussion. Cephalgia 2016;36(4):309-16. PMID 26054363
54: Howell DR, Mannix RC, Quinn B, Taylor JA, Tan CO, Meehan WP. Physical activity level and symptom duration are not associated after concussion. Am J Sports Med 2016;44(4):1040-6. PMID 26838933
55: Howell DR, Osternig LR, Chou LS. Dual-task effect on gait balance control in adolescents with concussion. Arch Phys Med Rehabil 2013;94(8):1513-20. PMID 23643687
56: Iverson GL, Atkins JE, Zafonte R, Berkner PD. Concussion history in adolescent athletes with attention-deficit hyperactivity disorder. J Neurotrauma 2016;33(23):2077-80. PMID 25375785
57: Jalali R, Bałuch M, Malinowska J, et al. GFAP/UCH-L1 as a biomarker for rapid assessment of mild TBI in emergency departments. Med Sci Monit 2025;31:e948353. PMID 40498681
58: Johnson B, Gay M, Zhang K, et al. The use of magnetic resonance spectroscopy in the subacute evaluation of athletes recovering from single and multiple mild traumatic brain injury. J Neurotrauma 2012a;29(13):2297-304. PMID 22780855
59: Johnson B, Zhang K, Gay M, et al. Alteration of brain default network in subacute phase of injury in concussed individuals: resting-state fMRI study. Neuroimage 2012b;59(1):511-8. PMID 21846504
60: Karlin AM. Concussion in the pediatric and adolescent population: “different population, different concerns”. PM R 2011;(3)(10 Suppl 2):S369-79. PMID 22035679
61: Keightley ML, Saluja RS, Chen JK, et al. A functional magnetic resonance imaging study of working memory in youth after sports-related concussion: is it still working? J Neurotrauma 2014;31(5):437-51. PMID 24070614
62: Kerr ZY, Chandran A, Nedimyer AK, Arakkal A, Pierpoint LA, Zuckerman SL. Concussion incidence and trends in 20 high school sports. Pediatrics 2019;144(5);e20192180. PMID 31615955
63: Kerr ZY, Zuckerman SL, Register-Mihalik JK, et al. Estimating concussion incidence using sports injury surveillance systems: complexities and potential pitfalls. Neurol Clin 2017;35(3):409-34. PMID 28673407
64: Kinnaman KA, Mannix RC, Comstock RD, Meehan WP 3rd. Management of pediatric patients with concussion by emergency medicine physicians. Pediatr Emer Care 2014;30(7):458-61. PMID 24977993
65: Kirkwood MW, Peterson RL, Connery AK, Baker DA, Grubenhoff JA. Postconcussive symptom exaggeration after pediatric mild traumatic brain injury. Pediatrics 2014;133(4):643-50. PMID 24616360
66: Kontos AP, Elbin RJ, Fazio-Sumrock VC, et al. Incidence of sports-related concussion among youth football players aged 8-12 years. J Pediatr 2013;163(3):717-20. PMID 23751761
67: Kuczynski A, Crawford S, Bodell L, Dewey D, Barlow KM. Characteristics of post-traumatic headaches in children following mild traumatic brain injury and their response to treatment: a prospective cohort. Dev Med Child Neurol 2013;55(7):636-41. PMID 23560811
68: Kuppermann N, Holmes JF, Dayan PS, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet 2009;374(9696):1160-70. PMID 19758692
69: Larsen EL, Ashina H, Iljazi A, et al. Acute and preventive pharmacological treatment of post-traumatic headache: a systematic review. J Headache Pain 2019;20(1):98. PMID 31638888
70: Leddy JJ. Sport-related concussion. N Engl J Med 2025;392(5):483-93. PMID 39879594
71: Leddy JJ, Cox JL, Baker JG, et al. Exercise treatment for postconcussion syndrome: a pilot study of changes in functional magnetic resonance imaging activation, physiology, and symptoms. J Head Trauma Rehabil 2013;28(4):241-9. PMID 23249769
72: Leddy JJ, Haider MN, Ellis MJ, et al. Early subthreshold aerobic exercise for sport-related concussion: a randomized clinical trial. JAMA Pediatr 2019;173(4):319-25. PMID 30715132
73: Leddy JJ, Kozlowski K, Donnelly JP, Pendergast DR, Epstein LH, Willer B. A preliminary study of subsymptom threshold exercise training for refractory post-concussion syndrome. Clin J Sport Med 2010;20(1):21-7. PMID 20051730
74: Leddy JJ, Willer B. Use of exercise graded exercise testing in concussion and return-to-activity management. Curr Sports Med Rep 2013;12(6):370-6. PMID 24225521
75: Ledoux AA, Tang K, Yeates KO, et al. Pediatric Emergency Research Canada (PERC) Concussion Team. Natural progression of symptom change and recovery from concussion in a pediatric population. JAMA Pediatr 2019;173(1):e183820. PMID 30398522
76: Ledoux AA, Barrowman N, Bijelić V, et al. PERC PedCARE Concussion team. Is early activity resumption after paediatric concussion safe and does it reduce symptom burden at 2 weeks post injury? The Pediatric Concussion Assessment of Rest and Exertion (PedCARE) multicentre randomised clinical trial. Br J Sports Med 2022;56(5):271-8. PMID 34836880
77: Lichtenstein JD, Moser RS, Schatz P. Age and test setting affect the prevalence of invalid baseline scores on neurocognitive tests. Am J Sports Med 2014;42(2):479-84. PMID 24243771
78: Lumba-Brown A, Yeates KO, Sarmiento K, et al. Centers for Disease Control and Prevention Guideline on the Diagnosis and Management of Mild Traumatic Brain Injury Among Children. JAMA Pediatr 2018;172(11):e182853.** PMID 30193284
79: Macnow T, Curran T, Tolliday C, et al. Effect of screen time on recovery from concussion: a randomized clinical trial. JAMA Pediatr 2021;175(11):1124-31. PMID 34491285
80: Maddocks D, Dicker G. An objective measure of recovery from concussion in Australian rules footballers. Sport Health 1989;7:6-7.
81: Maddocks DL, Dicker GD, Saling MM. The assessment of orientation following concussion in athletes. Clin J Sport Med 1995;5(1):32-5. PMID 7614078
82: Mannix R, Eisenberg M, Berry M, Meehan WP, Hayes RL. Serum biomarkers predict acute symptom burden in children after concussion: a preliminary study. J Neurotrauma 2014;31(11):1072-5. PMID 24494742
83: Marar M, McIlvain NM, Fields SK, Comstock RD. Epidemiology of concussions among United States high school athletes in 20 sports. Am J Sports Med 2012;40(4):747-55. PMID 22287642
84: Marchi N, Bazarian JJ, Puvenna V, et al. Consequences of repeated blood-brain barrier disruption in football players. PLoS One 2013;8(3):e56805. PMID 23483891
85: Maugans TA, Farley C, Altaye M, Leach J, Cecil KM. Pediatric sports-related concussion produces cerebral blood flow alterations. Pediatrics 2012;129(1):28. PMID 22129537
86: Mayer AR, Ling JM, Yang Z, Pena A, Yeo RA, Klimaj S. Diffusion abnormalities in pediatric mild traumatic brain injury. J Neurosci. 2012 Dec 12;32(50):17961-9. PMID 23238712
87: McAllister TW, Flashman LA, Maerlender A, Greenwald RM, Beckwith JG, Tosteson TD, Crisco JJ, Brolinson PG, Duma SM, Duhaime AC, Grove MR, Turco JH. Cognitive effects of one season of head impacts in a cohort of collegiate contact sport athletes. Neurology 2012;78(22):1777-84. PMID 22592370
88: McClure DJ, Zuckerman SL, Kutscher SJ, Gregory AJ, Solomon GS. Baseline neurocognitive testing in sports-related concussions: the importance of a prior night’s sleep. Am J Sports Med 2014;42(2):472-80. PMID 24256713
89: McCrea M, Guskiewicz K, Randolph C, et al. Effects of a symptom-free waiting period on clinical outcome and risk of reinjury after sport-related concussion. Neurosurgery 2009;65(5):876-82. PMID 19834399
90: McCrea M, Guskiewicz K, Randolph C, et al. Incidence, clinical course, and predictors of prolonged recovery time following sport-related concussion in high school and college athletes. J Int Neuropsychol Soc 2013;19(1):22-33. PMID 23058235
91: McGrath N, Dinn WM, Collins MW, Lovell MR, Elbin RJ, Kontos AP. Post-exertion neurocognitive test failure among student-athletes following concussion. Brain Inj 2013;27(1):103-13. PMID 23252441
92: McGuine TA, Hetzel S, McCrea M, Brooks MA. Protective equipment and player characteristics associated with the incidence of sport-related concussion in high school football players: a multifactorial prospective study. Am J Sports Med 2014;42(10):2470-8. PMID 25060072
93: McKinlay A, Ligteringen V, Than M. A comparison of concussive symptoms reported by parents for preschool versus school-aged children. J Head Trauma Rehabil 2014;29(3):233-8. PMID 23982792
94: McNally KA, Bangert B, Dietrich A, et al. Injury versus noninjury factors as predictors of postconcussive symptoms following mild traumatic brain injury in children. Neuropsychology 2013;27(1):1-12. PMID 23356592
95: Meehan WP 3rd, Mannix R. Pediatric concussions in United States emergency departments in the years 2002 to 2006. J Pediatr 2010;157(6):889-93. PMID 20708747
96: Meehan WP 3rd, Mannix R, Monuteaux MC, Stein CJ, Bachur RG. Early symptom burden predicts recovery after sport-related concussion. Neurology 2014;83(24):2204-10. PMID 25381296
97: Meehan WP 3rd, Mannix RC, Stracciolini A, Elbin RJ, Collins MW. Symptom severity predicts prolonged recovery after sport-related concussion, but age and amnesia do not. J Pediatr 2013;163(3):721-5. PMID 23628374
98: Meehan WP 3rd, Zhang J, Mannix R, Whalen MJ. Increasing recovery time between injuries improves cognitive outcome after repetitive mild concussive brain injuries in mice. Neurosurgery 2012;71(4):885-91. PMID 22743360
99: Memmini AK, Snedden TR, Boltz AJ, et al. Factors influencing time to return to learn among NCAA student-athletes enrolled in the concussion assessment, research, and education (CARE) study. Sports Med 2024;54(7):1965-77. PMID 38407750
100: Morgan CD, Zuckerman SL, Lee YM, et al. Predictors of postconcussion syndrome after sports-related concussion in young athletes: a matched case-control study. J Neurosurg Pediatr 2015;15(6):589-98. PMID 25745949
101: Mucha A, Collins MW, Elbin RJ, et al. A brief vestibular/ocular motor screening (VOMS) assessment to evaluate concussions: preliminary findings. Am J Sports Med 2014;42(10):2479-86. PMID 25106780
102: Munoz Pareja JC, de Rivero Vaccari JP, Chavez MM, et al. Prognostic and diagnostic utility of serum biomarkers in pediatric traumatic brain injury. J Neurotrauma 2024;41(1-2):106-22. PMID 37646421
103: Olsson KA, Lloyd OT, Lebrocque RM, McKinlay L, Anderson VA, Kenardy JA. Predictors of child post-concussion symptoms at 6 and 18 months following mild traumatic brain injury. Brain Inj 2013;27(2):145-57. PMID 23384213
104: Patricios JS, Schneider KJ, Dvorak J, et al. Consensus statement on concussion in sport: the 6th International Conference on Concussion in Sport–Amsterdam, October 2022. British Journal of Sports Medicine 2023;57:695-711. PMID 37316210
105: Pearce JM. Observations on concussion. A review. Eur Neurol 2008;59(3-4):113-9. PMID 18057896
106: Pearson R, Levyim D, Choe M, Taraman S, Langdon R. Survey of child neurologists on management of pediatric post-traumatic headache. J Child Neurol 2019;34(12):739-47. PMID 31232148
107: Pertab JL, Merkley T, Winiarski H, Cramond K, Cramond A. Concussion and the autonomic, immune, and endocrine systems: an introduction to the field and a treatment framework for persisting symptoms. J Pers Med 2025;15(1):33. PMID 39852225
108: Ponsford J, Willmott C, Rothwell A, et al. Impact of early intervention on outcome after mild traumatic brain injury in children. Pediatrics 2001;108(6):1297-303. PMID 11731651
109: Puravet S, Oris C, Pereira B, et al. Serum GFAP and UCH-L1 for the identification of clinically important traumatic brain injury in children in France: a diagnostic accuracy substudy. Lancet Child Adolesc Health 2025;9(1):47-56. PMID 39637879
110: Putukian M, Purcell L, Schneider KJ, et al. Clinical recovery from concussion–return to school and sport: a systematic review and meta-analysis. Br J Sports Med 2023;57(12):798-809. PMID 37316183
111: Ransom DM, Vaughan CG, Pratson L, Sady MD, McGill CA, Gioia GA. Academic effects of concussion in children and adolescents. Pediatrics 2015;135(6):1043-50. PMID 25963014
112: Register-Mihalik J, Baugh C, Kroshus E, Y Kerr Z, Valovich McLeod TC. A multifactorial approach to sport-related concussion prevention and education: application of the socioecological framework. J Athl Train 2017;52(3):195-205. PMID 28387550
113: Rieger BP, Lewandowski LJ, Callahan JM, et al. A prospective study of symptoms and neurocognitive outcomes in youth with concussion vs orthopaedic injuries. Brain Inj 2013;27(2):169-78. PMID 23384214
114: Rose SC, McNally KA, Heyer GL .Returning the student to school after concussion: what do clinicians need to know? Concussion 2015;1(1):CNC4. PMID 30202549
115: Rubenstein R, Chang B, Yue JK, et al. Comparing plasma phospho tau, total tau, and phospho tau–total tau ratio as acute and chronic traumatic brain injury biomarkers. JAMA Neurol 2017;74(9):1063-72. PMID 28738126
116: Rubenstein R, McQuillan L, Wang KKW, et al. Temporal profiles of P-tau, T-tau, and P-tau:T-tau ratios in cerebrospinal fluid and blood from moderate-severe traumatic brain injury patients and relationship to 6–12 month global outcomes. J Neurotrauma 2024;41(3-4):369-92. PMID 37725589
117: Sanders MJ, Sick TJ, Perez-Pinzon MA, Dietrich WD, Green EJ. Chronic failure in the maintenance of long-term potentiation following fluid percussion injury in the rat. Brain Res 2000;861(1):69-76. PMID 10751566
118: Seiger A, Goldwater E, Deibert E. Does mechanism of injury play a role in recovery from concussion? J Head Trauma Rehabil 2015;30(3):E52-6. PMID 24901324
119: Shepherd HA, Yeates KO, Reed N, et al. Academic accommodations for middle and high school students following a concussion: perspectives of teachers and school administrators. J Sch Health 2023;93(12):1099-110. PMID 37386759
120: Silverberg ND, Iverson GL. Is rest after concussion "the best medicine.": recommendations for activity resumption following concussion in athletes, civilians, and military service members. J Head Trauma Rehabil 2013;28(4):250-9. PMID 22688215
121: Sim A, Terryberry-Spohr L, Wilson KR. Prolonged recovery of memory functioning after mild traumatic brain injury in adolescent athletes. J Neurosurg 2008;108(3):511-16. PMID 18312098
122: Smyth K, Sandhu SS, Crawford S, Dewey D, Parboosingh J, Barlow KM. The role of serotonin receptor alleles and environmental stressors in the development of post-concussive symptoms after pediatric mild traumatic brain injury. Dev Med Child Neurol 2014;56(1):73-7. PMID 23992222
123: Sroufe NS, Fuller DS, West BT, Singal BM, Warschausky SA, Maio RF. Postconcussive symptoms and neurocognitive function after mild traumatic brain injury in children. Pediatrics 2010;125(6):e1331-9. PMID 20478946
124: Stukas S, Higgins V, Frndova H, et al. Characterisation of serum total tau following paediatric traumatic brain injury: a case-control study. Lancet Child Adolesc Health 2019;3(8):558-67. PMID 31231066
125: Taylor AM. Neuropsychological evaluation and management of sport-related concussion. Curr Opin Pediatr 2012;24(6):717-23. PMID 23080132
126: Taylor CA, Bell JM, Breiding MJ, Xu L. Traumatic brain injury-related emergency department visits, hospitalizations, and deaths -- United States, 2007 and 2013. MMWR Surveill Summ 2017;66(9):1-16. PMID 28301451
127: Thomas DG, Apps JN, Hoffmann RG, McCrea M, Hammeke T. Benefits of strict rest after acute concussion: a randomized controlled trial. Pediatrics 2015;135(2):213-23. PMID 25560444
128: Toledo E, Lebel A, Becerra L, et al. The young brain and concussion: imaging as a biomarker for diagnosis and prognosis. Neurosci Biobehav Rev 2012;36(6):1510-31. PMID 22476089
129: Vagnozzi R, Signoretti S, Cristofori L, et al. Assessment of metabolic brain damage and recovery following mild traumatic brain injury: a multicentre, proton magnetic resonance spectroscopic study in concussed patients. Brain 2010;133(11):3232-42. PMID 20736189
130: Vagnozzi R, Signoretti S, Tavazzi B, et al. Temporal window of metabolic brain vulnerability to concussion: a pilot 1H-magnetic resonance spectroscopic study in concussed athletes--part III. Neurosurgery 2008;62(6):1286-95. PMID 18824995
131: Virji-Babul N, Borich MR, Makan N, et al. Diffusion tensor imaging of sports-related concussion in adolescents. Pediatr Neurol 2013;48(1):24-9. PMID 23290016
132: Walker A, Chapin B, Abisambra J, DeKosky ST. Association between single moderate to severe traumatic brain injury and long-term tauopathy in humans and preclinical animal models: a systematic narrative review of the literature. Acta Neuropathol Commun 2022;10(1):13. PMID 35101132
133: Wallace C, Zetterberg H, Blennow K, van Donkelaar P. No change in plasma tau and serum neurofilament light concentrations in adolescent athletes following sport-related concussion. PLoS One 2018;13(10):e0206466. PMID 30372457
134: Wang A, Zhou G, Kawai K, O'Brien M, Shearer AE, Brodsky JR. Benign paroxysmal positional vertigo in children and adolescents with concussion. Sports Health 2021;13(4):380-6. PMID 33528343
135: Wilde EA, McCauley SR, Hunter JV, et al. Diffusion tensor imaging of acute mild traumatic brain injury in adolescents. Neurology 2008;70(12):948-55. PMID 18347317
136: Wu A, Ying Z, Gomez-Pinilla F. The salutary effects of DHA dietary supplementation on cognition, neuroplasticity, and membrane homeostasis after brain trauma. J Neurotrauma 2011;28(10):2113-22. PMID 21851229
137: Yaramothu C, Goodman AM, Alvarez TL. Epidemiology and incidence of pediatric concussions in general aspects of life. Brain Sci 2019;9(10):257. PMID 31569649
138: Yeates KO, Taylor HG, Rusin J, et al. Longitudinal trajectories of postconcussive symptoms in children with mild traumatic brain injures and their relationship to acute clinical status. Pediatrics 2009;123(3):735-43. PMID 19254996
139: Yumul JN, Crowe L, Catroppa C, Anderson V, McKinlay A. Post-concussive signs and symptoms in preschool children: a systematic review. Neuropsychol Rev 2022;32(3):631-50. PMID 34390464
140: Zonfrillo MR, Kim KH, Arbogast KB. Emergency department visits and head computer tomography utilization for concussion patients from 2006-2011. Acad Emerg Med 2015;22(7):872-7. PMID 26111921
141: Zuckerman SL, Apple RP, Odom MJ, Lee YM, Solomon GS, Sills AK. Effect of sex on symptoms and return to baseline in sports-related concussion. J Neurosurg Pediatr 2014;13(1):72-81. PMID 24206343
142: Zuckerman SL, Brett BL, Jeckell AS, Yengo-Kahn AM, Solomon GS. Prognostic factors in pediatric sport-related concussion. Curr Neurol Neurosci Rep 2018;18(12):104. PMID 30397831

Contributors

All contributors' financial relationships have been reviewed and mitigated to ensure that this and every other article is free from commercial bias.

Author

Brittany Poinson MD MSEd

Dr. Poinson of Tulane University has no relevant financial relationships to disclose.
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Editor

Alcy R Torres MD FAAP

Dr. Torres of Boston Medical Center and Boston University Chobanian and Avedisian School of Medicine has no relevant financial relationships to disclose.
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Former Authors

Felicia Gliksman DO MPH FAAN
Michael V Johnston MD†
Ann Tilton MD

Patient Profile

Age range of presentation: 0 month to 18 years
Sex preponderance: Debated
Heredity: None
Population groups selectively affected: None
Occupation groups selectively affected: Athletics

ICD & OMIM codes

ICD-10: Concussion: S06.0X

Concussion without loss of consciousness: S06.0X0

Concussion with loss of consciousness of 30 minutes or less: S06.0X1

Concussion with loss of consciousness status unknown: S06.0XA

Concussion with loss of consciousness of unspecified duration: S06.0X9
ICD-11: Concussion: NA07.0

Concussion with incomplete loss of consciousness with amnesia: NA07.00

Concussion with incomplete loss of consciousness without amnesia: NA07.01

Concussion with loss of consciousness, short duration of less than 30 minutes: NA07.02

Concussion with loss of consciousness, short duration of 30 minutes to less than one hour: NA07.03

Concussion with loss of consciousness, short duration of one hour to less than 6 hours: NA07.04

Concussion with loss of consciousness, intermediate duration of 6 hours to less than 24 hours: NA07.05

Concussion with loss of consciousness, persisting longer than 24 hours or until discharge or latest assessment: NA07.06

Concussion with loss of consciousness, duration unspecified or unknown due to effects of therapy: NA07.08

Other specified concussion: NA07.0Y

Concussion, unspecified: NA07.0Z

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Cerebral concussion in childhood

Associated Disorders

Headache attributed to head trauma
Neurovascular injuries
Posttraumatic epilepsy
Posttraumatic sleep disturbance

Differential Diagnosis

Moderate - severe brain injury
Mental Health conditions and acute stress response
Migraines, medication overuse headache, chronic daily headache

Also Relevant

Chronic traumatic encephalopathy
Minor closed head injury
Severe closed head injury
Sports activities: neurologic complications

Cerebral concussion in childhood …

Cerebral concussion in childhood

Cite this article

Introduction

Overview

Key points

Historical note and terminology

Clinical manifestations

Presentation and course

Table 1. Common Concussive Symptoms

Preschool-aged children: monitoring

Prognosis and complications

Clinical vignette

Biological basis

Etiology and pathogenesis

Epidemiology

Prevention

Differential diagnosis

Associated or underlying disorders

Diagnostic workup

Management

Outcomes

References

Contributors

Author

Editor

Former Authors

Patient Profile

ICD & OMIM codes

This is an article preview.
Start a Free Account
to access the full version.

Questions or Comment?

Also in This Category

Mental status examination

Acute cerebellar ataxia in children

Turcot syndrome

Upadacitinib

Ataxia-telangiectasia

Self-limited (familial) infantile epilepsy

Developmental delay in children: evaluation and management

Neonatal opioid withdrawal syndrome

Cerebral concussion in childhood

Cite this article

Introduction

Overview

Key points

Historical note and terminology

Clinical manifestations

Presentation and course

Table 1. Common Concussive Symptoms

Preschool-aged children: monitoring

Prognosis and complications

Clinical vignette

Biological basis

Etiology and pathogenesis

Epidemiology

Prevention

Differential diagnosis

Associated or underlying disorders

Diagnostic workup

Management

Outcomes

References

Contributors

Author

Editor

Former Authors

Patient Profile

ICD & OMIM codes

This is an article preview. Start a Free Account to access the full version.

Questions or Comment?

Also in This Category

Mental status examination

Acute cerebellar ataxia in children

Turcot syndrome

Upadacitinib

Ataxia-telangiectasia

Self-limited (familial) infantile epilepsy

Developmental delay in children: evaluation and management

Neonatal opioid withdrawal syndrome

This is an article preview.
Start a Free Account
to access the full version.