Consensus Voting and Wording of the 2023 Living Guideline Updates

2021-2022 Updates (archive)

Updates to the clinical guideline recommendations in the Living Guideline for Pediatric Concussion Care will be shared below.
Last updated: May 9, 2022

Domain: 3 Prolonged concussion
Recommendation: 3.6
Update: Minor change in the wording for clarity: Initiate treatment for specific symptoms or concerns while waiting for referral to an interdisciplinary team or sub-specialist.
Minor update to 2.1b: Include the following risk factors: Vestibular-Ocular Reflex (VOR) and tandem gait parameters, Orthostatic intolerance.
Evidence:
Consensus: 100% (4/4) domain 3 experts approved
Status: Completed March 2022

Domain: 2 Acute concussion
Recommendation: 2.1b
Update: Minor update to 2.1b: Include the following risk factors: Vestibular-Ocular Reflex (VOR) and tandem gait parameters, Orthostatic intolerance
Evidence: Haider et al 2021
Consensus: 100% (6/6) domain 2 experts approved
Status: Completed February 2022

Domain: 8 Mental Health
Recommendation: Minor update to clinical algorithm (https://pedsconcussion.com/wp-content/uploads/Tool-8.1-Post-concussion-Mental-Health-Considerations-Algorithm.pdf)
Update: Add psychologists as referral targets to “clinically significant mood or anxiety symptoms” in the algorithm as per their scope of practice
Evidence: Expert consensus
Consensus: 75% (4/5) domain 8 experts approved
Status: Completed February 2022

Domain: 8 Mental Health
Recommendation: Minor update to domain 8- sharing the MyHeartsMap tool for emergency physicians. This tool would be shared under the present recommendation 8.1 “Assess existing and new mental health symptoms and disorders“
Update: The online tool is designed to help clinicians complete an efficient comprehensive psychosocial evaluation for children and youth presenting with mental health or psychosocial concerns, while the self-assessment version can be completed by patients/parents directly. Both versions collect information about 10 domains: Home, Education and activities, Alcohol and drugs, Relationships and bullying, Thoughts and anxiety, Safety, Sexual health, Mood, Abuse, and Professionals and resources. Link to the open version: MyHeartsMap
Evidence: Experts in this group recommended that we consider this tool based on: Lameroux et al 2021, Virk et al 2019.
Consensus: XXX domain 8 experts approved
Status: Not completed

Domain: Return to school (12)
Recommendation: 12.1 and the return to school introduction
Update: 12.1 The child/adolescent should return to their school environment as soon as they are able to tolerate engaging in cognitive activities without exacerbating their symptoms, even if they are still experiencing symptoms. Recommend a stepwise return-to-school plan. Include temporary accommodations based on symptoms and recommendations from the healthcare professional. Monitor and modify the return-to-school plan based on ongoing assessment of symptoms. Level of Evidence: B
12.1a Complete absence from the school environment for more than one week is generally not recommended. Children/adolescents should receive temporary academic accommodations (e.g, modifications to schedule, classroom environment and workload) to support a return to the school environment in some capacity as soon as possible. Level C (C = Consensus, usual practice, opinion or weaker-level evidence)
Introduction: Parents and/or caregivers need to be made aware that most youth will experience symptom resolution and full return to daily activities following a concussion; however this is highly variable and individual. Complete absence from the school environment for more than one week is generally not recommended, however, it is reasonable for a child/adolescent to miss some school after a concussion, regardless of symptoms. The child/adolescent should gradually return to their school environment as soon as they are able to tolerate engaging in cognitive activities without exacerbating their symptoms, even if they are still experiencing symptoms. It is important not to allow or encourage the child/adolescent to “settle into the habit” of missing school. The school setting provides beneficial contact with peers and social support.
Introduction to domain 2: “Complete absence from the school environment for more than one week is generally not recommended. The child/adolescent should gradually return to their school environment (with academic accommodations) as soon as they are able to tolerate engaging in cognitive activities without exacerbating their symptoms, even if they are still experiencing symptoms”
Evidence: Level C- Expert consensus (C = Consensus, usual practice, opinion or weaker-level evidence.)
Consensus: 91% (32/35)- approved or approved with minor suggestions
Quorum: 87.5 % of experts voted (35/40)
Minor revision: clarifying that in-person school absence for more than one week is“generally” not recommended
Status: Completed February 2022

Domain: Domain 2 and 3 (Acute and prolonged concussion)
Recommendation: 2.9 and new 2.9a, 3.3, and introductions domain 2 and 3 (also shared in domain 6- headache, domain 7- sleep, domain 10- vestibular/oculomotor/vision, 11- fatigue)
Update: 2.9 Refer patients at elevated risk for delayed recovery to an interdisciplinary concussion team. Level of Evidence: A2.9a Specialized interdisciplinary concussion care is ideally initiated for patients at elevated risk for a delayed recovery within the first two weeks post-injury. Level of Evidence: B
Introductions of domains 2 and 3: Domain 2: “For those at risk of a prolonged recovery, specialized interdisciplinary concussion care is ideally initiated within the first two weeks post-injury.” Domain 3: “For those at risk of a prolonged recovery, specialized interdisciplinary concussion care is ideally initiated within the first two weeks post-injury. Patients who are active, competitive athletes, and those who are not tolerating a gradual return to physical activity may benefit from early assessment of their sub-symptom threshold aerobic exercise tolerance and prescribed aerobic exercise as early as 48 hours following acute injury.”
Evidence: Kontos et al 2020
Consensus: 94% (33/35 expert panel members voted to agree with the new recommendation or agree with minor revision suggestions)
Quorum: 85% of experts voted (35/40)
Status: Completed March 2022

Domain: Domain 2 and 3 (Acute and prolonged concussion)
Recommendation: 2.3d and 3.3 (Return to activity)
Update: Refer select patients (e.g., highly-active or competitive athletes, those who are not tolerating a graduated return to physical activity, or those who are slow to recover) following acute injury to a medically supervised interdisciplinary team with the ability to individually assess sub-symptom threshold aerobic exercise tolerance and to prescribe aerobic exercise treatment. This exercise tolerance assessment can be as early as 48 hours following acute injury. Level of Evidence: A
Patients who are active may benefit from referral to a medically supervised interdisciplinary team with the ability to individually assess sub-symptom threshold aerobic exercise tolerance and to prescribe aerobic exercise treatment. This exercise tolerance assessment can be as early as 48 hours following acute injury. Level of Evidence: C (expert consensus)
Evidence: Leddy et al 2021 (RCT)
Consensus: 100% 36/36 agreed or agreed with minor revision suggestions. Quorum: 90% experts voted (36/40), Minor revision: specifying “exercise tolerance assessment” being started vs “referral” initiated at 48-72 hours.
Status: Completed March 2022

Domain: 15- Telemedicine and Virtual Care
Recommendation: Tool 15.2: Virtual Care Exam Training Resource
Update: Virtual Care Exam Training Resource: A training manual to assist front-line healthcare professionals who are caring for patients that cannot be seen in person or have already had an in-person assessment and require follow-up.
Consensus: 91%, 30/33 of experts on the expert panel reviewed and voted to include. Quorum: 87%. 33/38 exert panel members participated in the vote. *Two expert panel members were authors and were not included in the vote. Two project leads (RZ and NR) are also authors and did not participate in the vote or decision making
Status: Completed May 2021

Domain:Domain 1-Concussion Recognition and Directing to Care
Recommendation:1.3
Update:Minor revision (red): If a child/adolescent demonstrates any of the ‘Red Flags’ indicated by the Concussion Recognition Tool 5, a more severe head or spine injury should be suspected and an emergency medical assessment is required. These red flag symptoms may appear immediately or within a few hours or days after injury. Delayed red flag symptoms also require urgent medical assessment as they may indicate a more severe injury. Consider arranging an ambulance service as necessary to facilitate urgent medical assessment at the nearest hospital and execution of the Emergency Action Plan for your organization. When calling an ambulance, describe the specific red flags symptoms over the phone
Evidence:Eagle et al 2020, Borland et al 2019
Consensus:100% consensus (Domain 1 and 2 expert panel members voted for this minor revision)
Status: Completed May 2022

Domain:Domain 1-Concussion Recognition and Directing to Care
Recommendation:1.4
Update:Minor revision (red): Concussion should be suspected and diagnosed as soon as possible to maintain health and improve outcomes. Concussion can be suspected in the community by healthcare professionals, parents, teachers, coaches, and peers. Those with a suspected concussion should be assessed by a physician or nurse practitioner to perform a thorough medical assessment to exclude more severe injuries, consider a full differential diagnosis, and confirm the diagnosis of concussion. It is important to note that some patients may experience a delayed onset of concussion symptoms. Delayed concussion symptoms also require medical assessment to exclude more severe injuries
Evidence:Eagle et al 2020 and Borland et al 2019
Consensus:100% consensus(Domain 1 and 2 expert panel members voted for this minor revision)
Status: Completed May 2022

Domain: Domain 15-Telehealth and Virtual Care
Recommendation: Recommendations 15.1-15.6 Considerations for a virtual medical assessment and follow-up. Tools 15.1 and 15.2 (Algorithm and physical exam)
Update:New set of recommendations. See Domain 15
Evidence:See Domain 15 Reference list
Consensus:93% (full expert team vote that included 27/35 of the active panel members (77% quorum)
Status: Complete

Domain:2- Initial Diagnosis and Management
Recommendation:2.3. Graduated return to physical and cognitive activity
Update:New Recommendation:  Update recommendation 2.3 to include a section “d” that shares the suggestion to consider referring select patients (e.g., highly active or competitive athletes and/or those who are not tolerating a graduated return to physical activity) to a medically supervised inter-disciplinary team with the ability to individually assess sub-symptom threshold aerobic exercise tolerance and to prescribe aerobic exercise treatment.
Evidence:Coclick et al 2020, Haider et al 2020,  DeMatteo et al 2020, Del Rossi et al 2020, Root et al 2020, Sharma et al 2020, Marshall et al 2020, Leddy et al 2019, Chan et al 2018, See domain 2 reference link for a full list.  . New- Dec 2020 paper under consideration: Langevin et al 2020 .
Consensus:93% (full expert team vote, that included 36/39 of the active panel team member experts)
Status: Completed 2021

Domain:2- Initial Diagnosis and Management
Recommendation:2.2 Return to School
Update:Minor clarification: Highlight the return to school information from Domain 12 by including information about  Acute academic adjustments for concussion and give examples of academic adjustments to help support students transitioning back to school
Evidence:Master et al 2020
Consensus:50% (not added)
Status: Not completed

Domain:7- Sleep
Recommendation:
Update:Minor revision: Add in a star to the melatonin recommendation that includes: “Melatonin was not found to be effective when used for youth with concussion symptoms 4-6 weeks after injury in a single-center double-blinded randomized controlled trial” (Barlow et al 2020. Efficacy of Melatonin in Children With Postconcussive Symptoms: A Randomized Clinical Trial. Pediatrics)
Evidence:Barlow et al 2020
Consensus: 100%
Status: Complete

Domain:7- Sleep
Recommendation:
Update:A review of the timing of the recommended use of Melatonin and the dose has been suggested
Evidence:Barlow et al 2020 (pediatrics), Iyver et al 2020, Barlow et al 2020 (Ped Neurol)
Consensus: Not completed
Status: Not completed

Domain:7- Sleep
Recommendation:
Update:A minor revision to the introduction, adding in: “Medication use, headaches and mental health conditions (e.g. anxiety, depression) may also affect sleep. Poor sleep may be related to cognitive complaints and worse post-concussion symptoms. “
Evidence:Ludwig et al, 2020, Starkey et al 2016,
Consensus: 100%
Status: Complete

Domain:2- Initial Diagnosis and Management
Recommendation:2.1b: Note common modifiers that may delay recovery and use a clinical risk score to predict risk of prolonged
Update:Minor Revision: Update the list of modifiers for a prolonged recovery to include: High symptom burden at initial presentation, clinical evidence of vestibular or oculomotor dysfunction, duration of recovery from a previous concussion.
Evidence:Zemek et al 2016, Beauchamp et al 2018, Ellis et al 2018, Fehr et al 2019, Guerriero et al 2018, Howell et al 2018, Howell et al 2018, Ledoux et al 2019,  Master et al 2018,  Yeates et al 2019
Consensus:100%
Status: Complete

Domain:2- Initial Diagnosis and Management
Recommendation:2.2: Provide verbal information and written (electronic) handouts regarding the course of recovery and when the child/adolescent can return to school/activity/sport/work
Update:Minor Revision: Include a sentence sharing that the information that females aged 13-18 years have an increased risk of a prolonged recovery.
Evidence:Ledoux et al 2019
Consensus: 83%
Status: Complete

Domain:7- Sleep

Recommendation:Introduction
Update:Minor Revision: Update the 4th sentence of the introduction to include: “Medication use, headaches and mental health conditions (e.g. anxiety, depression) may also affect sleep. Poor sleep may be related to cognitive complaints and worse post-concussion symptoms. A repeat…”
Evidence:Murdaugh et al 2018, Wiseman-Hakes et al 2019
Consensus: 100%
Status: Complete

Domain:4- Medical Clearance
Recommendation:4.1: Child/adolescent has successfully returned to all school activities including writing exams without symptoms above their previous pre-injury level or requiring accommodations related to their concussion/post-concussion symptoms.
Update:Minor revision:Update level of evidence
Evidence:Dematteo et al 2019
Consensus: 100%
Status: Complete

Domain:12- Return to School and Work
Recommendation:12.5: Return-to-school and return-to-sport strategies can be performed simultaneously. Recommend that the child/adolescent return-to-school full-time at a full academic load, including writing exams without accommodations related to their concussion/post-concussion symptoms, before returning to full-contact sport or high-risk activities.
Update:Minor Revision:Update level of evidence to
Evidence:Dematteo et al 2019
Consensus: 80%
Status: Complete

*Consensus for minor revisions: Minimum three domain experts vote on minor revisions. 75% consensus is required to proceed with a minor revision. Please see the Methodology Living Guideline pdf for more information.
** Consensus for minor revisions: Minimum three domain experts vote on minor revisions. 75% consensus is required to proceed with a minor revision. Please see the Methodology Living Guideline pdf for more information. **Consensus for major revisions: A quorum of 75% of active expert panel members are required to vote on the improvement. 75% consensus is required to proceed with a major revision. A pediatric pharmacist will perform an additional review for any proposed changes in dosing. ** Definitions of the A, B, C level of evidence can be found here: Levels of Evidence

2021-2022: overview of updates

Living Guideline for Pediatric Concussion Care: list of recently updated concussion protocols and clinical guideline recommendations. For a full list of updates and information on the consensus process please see “download updates“.

The information below highlights several new concussion protocols and clinical guideline recommendations related to the diagnosis and management of pediatric concussion that have changed since the 2014 Guideline on the Diagnosis and Management of Pediatric Concussion.

Considerations for telemedicine and virtual concussion care

In January 2021 the Living Guideline team released a new set of recommendations that include a clinical algorithm for determining when a child or adolescent would benefit from a virtual consultation (versus in-person). In January 2022 a new resource has been added to this domain, an interactive training manual that includes videos designed to assist front-line healthcare professionals who are caring for patients that cannot be seen in person or have already had an in-person assessment and require follow-up.

• Click here to access the new recommendations
• Tool 15.1: Considerations for Telemedicine and Virtual Care Algorithm 
• Tool 15.2 Considerations for a virtual physical examination for medical assessment and follow-up of concussion patients
• Tool 15.3: Virtual Care Exam Training Resource. A training manual to assist front-line healthcare professionals who are caring for patients that cannot be seen in person or have already had an in-person assessment and require follow-up. Please see “Recent Clinical Guideline Updates” for more information about how this tool was reviewed and selected for inclusion in the guideline by our expert panel.

Diagnosing Concussion:

 Resuming Activity After a Concussion:

Prolonged rest beyond the first 24-48 hours after a concussion is no longer recommended and may cause more harm than good. After an initial rest period (24-48 hours), children/adolescents should gradually resume low-risk activity, even in the presence of post-concussion symptoms. Return to physical and cognitive activity should be gradual and individualized based on activity tolerance and symptom presentation (e.g., the child/adolescent is able to engage in an activity without worsening of post-concussion symptoms). Activities that pose a risk for a repeated concussion must be avoided when still experiencing symptoms. See Recommendation 2.3 for more information. 

Highly active children/adolescents, those in competitive sport, those who are not tolerating a graduated return to physical activity, or those who are slow to recover may benefit from early referral to a medically supervised interdisciplinary team with the ability to individually assess sub-symptom threshold aerobic exercise tolerance and to prescribe aerobic exercise treatment.

Risk Factors for a Delayed Recovery (Risk-Modifiers That May Delay Recovery):

Consider referring children or adolescents who have a higher risk for a delayed recovery to an interdisciplinary concussion team earlier than 4-weeks post-concussion.

Return-to-School and Sports

Children and adolescents should return to a full school load, without accommodation, before they return to full-contact sport and game play.

Baseline testing is not recommended or required for concussion diagnosis or management in children or adolescents.

According to Parachute Canada’s Statement on Baseline Testing, baseline testing is “the practice of having an athlete complete certain concussion assessment tools/tests prior to sports participation to provide baseline measurements that can be compared to post-injury values in the event of a suspected concussion”. Current evidence does not support a significant added benefit of using baseline testing in children and adolescents.  See Recommendation 5.2 for more information.

Early identification of common mental health disorders and risk factors for mental health disorders may prevent/mitigate additional problems such as learning and behavior problems, school avoidance, and exacerbation of pre-existing problems in children/adolescents who are recovering from a concussion.