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  • Updated 04.08.2024
  • Released 07.21.2012
  • Expires For CME 04.08.2027

Cerebral concussion in childhood



Concussion, also known as mild traumatic brain injury, is a complex, multifactorial condition that is gaining awareness worldwide, but ironically, has a great deal of uncertainty surrounding the diagnosis. The author will discuss the known definitions, presentation of symptoms, known prognostic factors, as well as current recommendations for management. What is understood is that a concussion results from a biomechanical force transmitted to the brain inducing a series of neurometabolic changes that reflect a functional disturbance rather than a structural injury (95). Differences in stature and nervous system physiology of children leads to unique susceptibility to concussive injury. Similar to adults, symptoms indicate disruption of global brain function, including cognitive, emotional, physical, and sleep dysfunction; however, the recovery time is often prolonged in the pediatric population. Management of pediatric concussion is also distinctive given the cognitive demands of children in school. That can include immediate removal from play, a brief period of cognitive and physical rest, evaluation by a provider trained in concussion management, return to learning with appropriate academic accommodations, and, once clearance is provided, return to sports/physical activities following a supervised gradual return to play program. Proper management at the time of injury is essential given the risk of second impact syndrome or diffuse cerebral swelling, unique to the younger population.

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. 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 (96). 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. 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

Concussion “grading scales” attempting to stratify concussion severity were utilized in the past, but are no longer recommended (82). The SCAT6 (Sports Concussion Assessment Tool, Version 6) is 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 utilized to provide standardized and age appropriate guide to management. These tools utilize Maddocks’ questions as well as the Standardized Assessment of Concussion (SAC) (70; 71; 27).

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.

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