More Conservative Approach to Concussions in Children, Teens Recommended

Because the brain of the young athlete is still developing, with even subtle damage leading to learning deficits adversely affecting development, and with studies showing younger athletes recover more slowly than adults, a more conservative approach to concussions in children and teens than for older athletes is recommended by all major medical groups:

1. American Academy of Pediatrics Clinical Report, 2010 (Halstead, 2010)

• Individualized RTP: Return to play should follow an individualized course, because each athlete will recover at different rate.
• No same day RTP:  Under no circumstances should pediatric or adolescent athletes with concussion return to play the same day of their concussion.
• More conservative management: Because a number of studies have shown that younger athletes take longer to fully recover cognitive function than college-aged or professional athletes, a more conservative approach should be taken in deciding when pediatric and adolescent athlete can return to play, even when they show no symptoms of concussion.

2. Fourth International Conference on Concussion in Sport, Zurich 2012 (McCrory, 2013):

• No return to sport before return to school.  No return to sport should occur before the child/adolescent has managed to return to school successfully and is clinically symptom-free, which may take longer than for adults.
• More conservative RTP approach: the Zurich statement recommends that, in general, a more conservative return to play approach apply than for adults, including extending the physical and cognitive rest period, extending the amount of time of asymptomatic rest before and/or the length of time an athlete takes to complete the stepwise return to play exercise program.

3. The National Athletic Trainers' Association 2014 Position Statement: Management of Sport-Related Concussion (Broglio, 2014) recommends that "special consideration must be given to the young athlete," that perhaps they should be restricted from further participation on the day of injury, and that "additional consideration should be given as to when to return these individuals to activity"based on the fact that:

• The brain of the young athlete is still developing and the effects of concussion on the developing brain are not yet completely understood
• Even subtle damage can lead to learning deficits adversely affecting development
• High school athletes take longer to recover than collegiate athletes, with slower resolution of self-reported symptoms for high school athletes.
• Concussed high school athletes demonstrated prolonged memory dysfunction, and performed significantly worse on select memory tests than age-matched control subjects at 7 days post-injury compared to college athletes in a 2003 study.
• Sport-related head injury has a relatively high incidence rate and is a significant public health concern in youth athletes in general, not just participants at higher competitive levels.

4. The American College of Sports Medicine's 2006 Consensus Statement on Concussion (Mild Traumatic Brain Injury) and the Team Physician (ACSM, 2006) recognizes age as a factor in return-to-play decisions because "the developing brain may react differently to trauma than [a] mature brain."

• Return-to-play guidelines for young athletes need to be especially conservative given recent research by the University of Pittsburgh Medical Center as part of an NFL project to study recovery from concussions.  The research showed that professional football players recover from concussions faster than high school players. A majority of NFL players tested were back to their pre-season score levels within a week of injury, while a majority of the high school players still had slower reaction times and verbal memory skills seven days after suffering a concussion.
• Based on numerous studies showing that brain connections and growth aren't complete until a person reaches his mid-20's, researchers speculate that high school athletes' brains may be slower to recover from concussions than pro players because their brains have not fully matured. 

Sources: 

American College of Sports Medicine's 2006 Consensus Statement on Concussion(Mild Traumatic Brain Injury) and the Team Physician

Halstead, M, Walter, K.Clinical Report - Sport-Related Concussion in Children and Adolescents. Pediatrics 2010;126(3): 597-615. 

Giza C, Kutcher J, Ashwal S, et. al. Summary of evidence-based guideline update: Evaluation and management of concussion in sports: Report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology2013 (published online ahead of print March 18, 2013): DOI:10.1212/WNL.ob013e31828d57dd (accessed March 23, 2013)

Guskiewicz, Kevin, et al. National Athletic Trainers' Association Position Statement: Management of Sport-Related Concussion. J  Athl Tr2004; 39(3): 280-297. 

McCory, P. et al. Consensus statement on concussion in Sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med 2013;47:250-258.