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What is the difference in concussion management in children as compared with adults? A systematic review
  1. Gavin A Davis1,
  2. Vicki Anderson1,
  3. Franz E Babl1,
  4. Gerard A Gioia2,
  5. Christopher C Giza3,
  6. William Meehan4,
  7. Rosemarie Scolaro Moser5,
  8. Laura Purcell6,
  9. Philip Schatz7,
  10. Kathryn J Schneider8,
  11. Michael Takagi1,
  12. Keith Owen Yeates9,
  13. Roger Zemek10
  1. 1 Murdoch Childrens Research Institute, Melbourne, Australia
  2. 2 Children’s National Health System, Maryland, USA
  3. 3 UCLA Steve Tisch BrainSPORT Program, Los Angeles, USA
  4. 4 Micheli Center for Sports Injury Prevention, Massachusetts, USA
  5. 5 Sports Concussion Center of New Jersey, New Jersey, USA
  6. 6 Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
  7. 7 Saint Joseph's University, Pennsylvania, USA
  8. 8 Sport Injury Prevention Research Centre, Faculty of Kinesiology, Alberta Children's Hospital Research Institute, Hotchkiss Brain Institute, Cummings School of Medicine, University of Calgary, Calgary, Canada
  9. 9 Department of Psychology, Alberta Children’s Research Institute & Hotchkiss Brain Institute, University of Calgary, Calgary, Canada
  10. 10 Department of Pediatrics, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Canada
  1. Correspondence to Prof Gavin A Davis, Suite 53 – Neurosurgery, Cabrini Medical Centre Malvern, Victoria 3144 Australia; gavin.davis{at}


Aim To evaluate the evidence regarding the management of sport-related concussion (SRC) in children and adolescents. The eight subquestions included the effects of age on symptoms and outcome, normal and prolonged duration, the role of computerised neuropsychological tests (CNTs), the role of rest, and strategies for return to school and return to sport (RTSp).

Design Systematic review.

Data sources MEDLINE (OVID), Embase (OVID) and PsycInfo (OVID).

Eligibility criteria for selecting studies Studies were included if they were original research on SRC in children aged 5 years to 18 years, and excluded if they were review articles, or did not focus on childhood SRC.

Results A total of 5853 articles were identified, and 134 articles met the inclusion criteria. Some articles were common to multiple subquestions. Very few studies examined SRC in young children, aged 5–12 years.

Summary/conclusions This systematic review recommends that in children: child and adolescent age-specific paradigms should be applied; child-validated symptom rating scales should be used; the widespread routine use of baseline CNT is not recommended; the expected duration of symptoms associated with SRC is less than 4 weeks; prolonged recovery be defined as symptomatic for greater than 4 weeks; a brief period of cognitive and physical rest should be followed with gradual symptom-limited physical and cognitive activity; all schools be encouraged to have a concussion policy and should offer appropriate academic accommodations and support to students recovering from SRC; and children and adolescents should not RTSp until they have successfully returned to school, however early introduction of symptom-limited physical activity is appropriate.

Systematic review registration PROSPERO 2016:CRD42016039184

  • Concussion
  • children
  • adolescents
  • sport

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  • Competing interests GAD is an honorary member of the Australian Football League Concussion Working Group and has attended meetings organised by sporting organisations including the NFL (USA), National Rugby League (Australia) and FIFA(Switzerland); however, he has not received any payment, research funding or other monies from these groups other than for travel costs. GAG receives royalties as a test author from Psychological Assessment Resources, receives research funding from the CDC and NIH, receives speaking Honoria for professional lectures, and is on the pediatric mild traumatic brain injury guidelines panel of the CDC. CCG receives grants/research support from NIH, NCAA, DoD, Today’s and Tomorrow’s Children Fund, UCLA Brain Injury Research Center, UCLA Faculty Grants Program, UCLA Steve Tisch Brain SPORT program, Avanir (research grant 2016-2017), NINDS Neural Analytics SBIR grant (2016-2018) Consultant:NFL-Neurological Care Program, NHLPA, Neural Analytics Inc (2015-16), is on the advisory panel of Love Your Brain, MLS, NBA, NCAA, USSF, performs medicolegal work 1-2 cases annually, and speaks on the Medical Education Speakers Network. WM has received research grants from National Hockey League Alumni Association & NFL Players Association, receives publishing royalties from Wolters Kluwer, Springer International & ABC-Clio publishing. RSM receives consultancy fees from Leigh Valley Hospital, is the owner/director of Sports Concussion Center of New Jersey, speakers fees from National Academy of Neuropsychology; Nemours Dupont Children's Hospital; Notre Dame High School, Lawrenceville, NJ., Pearson International, publishing royalties from Dartmouth College Press, & Psychology Press, and travel expenses from Moms TEAM Institute. LP is an expert consultant to mdBriefcase in the development of an online concussion education module and has received speaking honoraria/travel expenses for presentations at scientific meetings. PS serves as a scientific consultant to ImPACT Applications, Inc., and is a member of their scientific advisory board. KJS has received speaking honoraria for presentations at scientific meetings. She is a physiotherapy consultant at Evidence Sport and Spinal Therapy in Calgary, Alberta, Canada, and for athletic teams. MT has received research grant from Royal Children's Hospital Foundation. KOY has received grant funding from NIH and Canadian Institutes of Health Research and book royalties from Guilford Press and Cambridge University Press and has occasionally served as an expert witness in forensic cases; he is President-Elect of the International Neuropsychological Society and a member of the Expert Panel on Acute Diagnosis and Management of Mild Traumatic Brain Injury among Children and Adolescents convened by the Centers for Disease Control and Prevention. RZ holds active grants in pediatric concussion from CIHR, Ontario Neurotrauma Foundation, and the Ontario SPOR Support Unit; and his work is partially supported by the University of Ottawa Brain and Mind Research Institute through a clinical research chair in pediatric concussion. VA, FEB have nothing to declare.

  • Provenance and peer review Commissioned; externally peer reviewed.

  • Correction notice This paper has been amended since it was published Online First. Owing to a scripting error, some of the publisher names in the references were replaced with 'BMJ Publishing Group'. This only affected the full text version, not the PDF. We have since corrected these errors and the correct publishers have been inserted into the references.