Living Guideline Updates

Last update: Jan 24, 2022

Please see the Living Guideline Methodology section for information about how the updates are performed and how the website is kept up to date.

Summary of New Evidence:

The information below highlights several 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.

Diagnosing Concussion:

Children and adolescents with a suspected concussion should be referred to a physician or nurse practitioner to perform a comprehensive medical assessment to exclude more severe injuries, consider a full differential diagnosis, and confirm the diagnosis of concussion.    Routine neuroimaging (CT scan or MRI) is not required for diagnosing a concussion. A CT scan of the brain or cervical spine is only recommended for cases of a suspected structural intracranial or cervical spine injury.

 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.

Mental Health

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.      



A systematic review protocol for assessing equity in clinical practice guidelines for traumatic brain injury and homelessness

We started a "Pediatric Concussion" Twitter List
We thought it would be an opportunity to connect the community & work together to ensure everyone with a concussion gets the best possible evidence-based care!

Please follow the list & share if interested!

#PedsConcussion Diagnosis?

Refer to an interdisciplinary concussion team:

✔️Athlete/active➡️REFER RIGHT AWAY (Aerobic exercise threshold testing as early as 1-2d)
✔️Increased risk slow recovery ➡️REFER RIGHT AWAY
✔️ANYONE not improving after 2-4w

Have you been diagnosed with a concussion or an anxiety disorder? Consider participating in our research study to help us learn about mental health outcomes to improve treatments for youth. Learn more here:

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