CDC PEDIATRIC mTBI GUIDELINE

Checklist

For healthcare providers treating children 18 years of age and younger

HEALTHCARE PROVIDERS SHOULD:

ASSESS.

Conduct a physical examination to identify findings that:

• Suggest more severe TBI (e.g., hemotympanum, pupillary asymmetry).

• May impact management of mTBI (e.g., concurrent injuries or baseline 

deficits, oculomotor dysfunction).

• Suggest other contributions to symptoms (e.g., dehydration, cervical 

tenderness, scalp hematoma).

Do not image routinely (including CT & MRI).

• Use validated clinical decision rules predicting risk for more severe injury 

to determine need.

Assess symptoms using validated scales. Consider cognitive and balance testing. 

Conduct a history to identify risk factors for poor prognosis using validated 

prediction rules.

A combination of risk factors that may indicate need 

for neuroimaging include:

• Age < 2 years old

• Recurrent vomiting

• Loss of consciousness

• Severe mechanism of injury

• Severe or worsening headache

• Amnesia

• Non-frontal scalp hematoma

• Glasgow Coma Score < 15

• Clinical suspicion for skull fracture

• Post-Concussion Symptom Scale

• Health and Behavior Inventory

• Post-Concussion Symptom Inventory

• Acute Concussion Evaluation

Examples of validated scales include, but aren’t 

limited to: 

Factors associated with poor prognosis:

• Older age (older children/adolescents) or 

Hispanic ethnicity

• Lower socio-economic status

• History of intracranial injury

• Premorbid histories of mTBI or increased 

pre-injury symptoms

• Neurological or psychiatric disorder

• Learning difficulties or lower cognitive ability

• Family and social stressors

COUNSEL.

Provide information about: 

• Warning signs that injury may be more serious.

• Typical recovery course.

• How to prevent further injury.

• Gradual re-introduction of activity that does not worsen symptoms.

• The need for social and emotional support.

Offer clear instructions (preferably verbal and written) on return to activity, 

including school and sports, customized to the patient’s symptoms.

• After a few days of rest (2-3 days), begin light activity & then gradually 

re-introduce regular activities (not inclusive of sports) that do not 

significantly worsen symptoms.

• Assess school-related needs & monitor progress in collaboration 

with parents and school professionals.

• Once back to regular non-sports activities (including school), patient 

can begin return to sports using a standard progression with gradually 

increasing levels of physical exertion.

• No return to contact sports activity until symptom-free with exertion 

(including without the use of pain medication).

Parents should watch for warning signs:

• A headache that gets worse & does not go away

• Significant nausea or repeated vomiting

• Increased confusion, restlessness, or agitation 

• Slurred speech, drowsiness, or inability to wake up

• Weakness, numbness, or decreased coordination

• Loss of consciousness, convulsions, or seizures

Steps in a return to play progression generally include:

Step 1: Return to regular non-sports activities

Step 2: Light aerobic exercise 

Step 3: Sport-specific exercise 

Step 4: Non-contact training drills 

Step 5: Full contact practice

Step 6: Return to sport

REFER.

Identify and tailor treatment plans/referrals to address:

• Acutely worsening symptoms consider neuroimaging.

• Chronic headache non-opioid analgesia (monitor for overuse), 

multi-disciplinary evaluation.

• Vestibulo-ocular dysfunction vestibular rehabilitation.

• Worsening sleep problem sleep hygiene, sleep specialist. 

• Cognitive impairment treatment directed at etiology, neuropsychological evaluation.

• Emotional dysfunction psychotherapeutic evaluation and treatment. 

Refer patients whose symptoms do not resolve as 

expected with standard care after 4-6 weeks.

To view the full set of recommendations from the CDC Pediatric mTBI Guideline, visit www.cdc.gov/HEADSUP.