If a child sustains a head impact during sports followed by headache, dizziness, or confusion, remove them from play for the rest of the day; seek emergency medical care for repeated vomiting, progressive drowsiness, or worsening headache

Young athletes who continue playing after a concussion take on average 44 days to recover, compared to just 22 days for those removed from play immediately. If a child experiences any abnormal signs after a head blow, bench them for the day and do not permit return to play until cleared by a physician. "Red flag" emergency signs requiring immediate hospital evaluation include repeated vomiting, increasing drowsiness or difficulty awakening, worsening headache, slurred speech, or seizures.

Free. Involves removing the child from training or athletic competition for the remainder of the day. The friction is holding a player out during high-stakes games when the child insists they feel fine and coaches or parents want them to continue.

A clinical study tracking 69 adolescent athletes (mean age 15) with sports-related concussions demonstrated that athletes removed from play immediately took an average of 22.0 days to recover, whereas athletes who continued playing while symptomatic averaged 44.4 days to recovery (P=0.003). Those continuing to play had 8.8 times higher odds of protracted recovery exceeding 21 days (OR 8.80). The 6th International Conference on Concussion in Sport (Amsterdam 2022 Consensus Statement) establishes that when athletes exhibit loss of consciousness, seizure, balance instability, confusion, or behavioral alterations, they must be removed from play immediately and barred from returning on the same day. U.S. CDC HEADS UP guidelines mandate the "When in Doubt, Sit Them Out" rule, emphasizing that only qualified healthcare professionals can diagnose or clear concussions. The CDC details immediate emergency "red flag" indications: seizures, inability to recognize familiar people or places, repeated nausea and vomiting, progressive confusion or agitation, loss of consciousness, slurred speech, limb weakness/numbness, unequal pupil size, and intractable worsening headache.

Graded B because the comparison of immediate removal versus continued play is observational rather than a randomized trial. International consensus protocols recommend cognitive and physical rest (limiting screens) for the first 24–48 hours, followed by gradual symptom-titrated reintroduction of light activity. Contact sports and activities with fall risks require medical clearance. For helmet use in cycling and winter sports, see Chapter 22, Rule 12. For delayed subdural hematomas following head injury in the elderly, see Chapter 13, Rule 10.

Elbin RJ, Sufrinko A, Schatz P, et al. (2016). Removal From Play After Concussion and Recovery Time. Pediatrics, 138(3), e20160910. https://doi.org/10.1542/peds.2016-0910；Patricios JS, Schneider KJ, Dvorak J, et al. (2023). Consensus statement on concussion in sport: the 6th International Conference on Concussion in Sport-Amsterdam, October 2022. British Journal of Sports Medicine, 57(11), 695-711. https://doi.org/10.1136/bjsports-2023-106898；CDC (2025). Signs and Symptoms of Concussion. HEADS UP. https://www.cdc.gov/heads-up/signs-symptoms/index.html；CDC. How to Respond. HEADS UP. https://www.cdc.gov/heads-up/response/index.html