Any child or adolescent who sustains a head injury while participating in a sport or recreational activity should immediately stop and be removed from the activity. If medical personnel are present, the athlete should be assessed using accepted emergency management procedures (airway, breathing, circulation). In an unconscious athlete, a cervical spine injury must be assumed and appropriate c-spine precautions should be initiated, including immobilization with board and collar and emergent transfer to hospital [4–6, 10, 48].

A conscious athlete should be assessed for signs and symptoms of concussion by medically trained personnel using a sideline assessment tool, such as the Sideline Concussion Assessment Tool 3 (SCAT3) for ages 13 years and older or the Child SCAT3 for ages 5–12 years [4, 49, 50]. The Child SCAT3 allows for parental input in the assessment of younger children.

The assessment of concussion should include a neurological exam and evaluation of cognitive function, including memory, attention, and concentration. If the athlete is deemed to be stable, he/she should not be left alone and should be closely observed for signs of deterioration [4–6, 10, 48]. The athlete should not return to play (RTP) on the day of injury and should not return to full participation until symptoms have completely resolved and clearance has been obtained by an experienced medical professional [4–6, 10, 48].

If medical personnel are not available on site, a responsible, trained adult, ideally the coach, trainer, or parent, should assess the injured athlete using the Concussion Recognition Tool (CRT) [4, 5, 51]. Urgent medical assessment should be arranged and the athlete should not return to play until medically cleared [4–6, 10].

Many child and youth sport activities and recreational activities occur without medical personnel on site. Therefore, the office or ED is the first point of contact for many injured athletes. A comprehensive medical assessment of a potentially concussed athlete should include a detailed history and thorough neurological exam. The history should elicit potential risk factors for prolonged recovery, such as previous head and facial injuries, including previous diagnoses of concussion; history of headaches/migraines in the patient and family; sleeping difficulties; learning disabilities or attention deficit/hyperactivity disorder (ADHD); and mental health issues [4–6]. The neurological exam should assess mental status, cognitive function, gait and balance. An important part of the assessment is the determination of the need for urgent imaging and management of other injuries [4]. The SCAT3 and ChildSCAT3 can be used in the office/ED setting for both initial and serial follow-up assessments [4–6, 49, 50].

If stable following initial assessment, an injured athlete should be observed at home by a responsible adult for the next 24–48 h for signs of deterioration, such as vomiting, decreased level of consciousness, worsening headache, or seizure activity. Patients should not be woken during the night, unless there are signs of deterioration, as sleep is an important part of concussion recovery. Signs of deterioration could indicate a more severe injury than a concussion that may require emergent medical management. The presence of any of these signs requires emergent reevaluation in the ED [5, 6].

Routine neuroimaging tests, such as skull X-rays, computed tomography (CT) scans, and magnetic resonance imaging (MRI), are not required for diagnosis of concussion. As concussion is a functional injury, not a structural injury, X-rays, CTs, and MRIs usually do not indicate any structural injury. Diagnostic tests should only be obtained if there is suspicion of a structural injury (decreased level of consciousness or prolonged loss of consciousness, seizure, focal neurological deficits) [4–6, 52].

There are specialized imaging techniques, such as functional MRI (fMRI), single-photon emission computed tomography (SPECT), and positron emission tomography (PET), which may indicate functional and physiological abnormalities associated with concussion. However, these techniques are not routinely available and are largely experimental [4].

Neuropsychological (NP) testing in various forms has been shown to be beneficial in assessing cognitive status in the setting of concussion [4, 53, 54]. It can be helpful in concussion management, particularly with respect to return to play decisions [4]. When used, NP testing is usually done once the patient is clinically symptom-free [4]. If NP testing is performed, it should be viewed as one component of the assessment process, in addition to clinical assessment and judgment, and not used as the sole basis for making management decisions [4, 5].

Pre-injury baseline testing may be helpful in the management of concussion; however, universal baseline testing is not recommended because of a lack of evidence to support this assertion [4, 48, 54, 55]. Particularly in children and adolescents, where rapid cognitive improvements between the ages of 9 and 15 years can confound NP results, the cost and lack of availability/resources make widespread pre-injury baseline testing impractical [4, 5, 39, 55, 56].

In certain cases, formal age-appropriate NP testing by a trained neuropsychologist may be necessary to aid the management of concussion [4, 5]. For instance, in athletes who have sustained multiple concussions or who are experiencing prolonged symptoms, formal NP testing may identify specific cognitive deficits that may help with educational planning [4, 5, 48, 54].

No medications have been studied in the treatment of acute concussion in children and adolescents. Acetaminophen and/or ibuprofen may help decrease the severity and duration of headache following concussion [5, 6, 10]. Medications have been used to treat specific prolonged symptoms of concussion, such as sleep disturbances, headache and mental health issues [5, 10, 59]. Medications that can mask the signs and symptoms of concussion should not be taken when returning to sport participation [4, 5].

In order to facilitate cognitive rest and allow concussion symptoms to diminish, injured student athletes may require a brief absence from school (usually a couple of days at most) [5, 6, 10, 37]. Once symptoms start to improve and students can increase cognitive tasks without exacerbating their symptoms, a gradual return to school can be initiated, starting with half days or only certain classes (Table 11.3) [5, 6, 10, 37, 48, 58, 60–62]. Students do not need to be completely symptom-free before returning to school; however, modifications and/or accommodations to their schedule and/or workload may be required (Table 11.4) [5, 6, 37, 48, 58, 60–62]. Students must return to a full academic load prior to returning to sports [5]. If a prolonged absence from school is required because of severe, persistent symptoms, referral to a specialist with experience in concussion and/or a neuropsychologist may be necessary to aid with education planning [5].