Return-to-school protocols in pediatric concussion care

Pediatric concussion frequently disrupts school participation, yet approaches to returning to the academic environment remain inconsistently implemented despite growing consensus on the benefits of early, supported school re-entry. This review synthesizes the extant literature on the evidence, clinical guidelines, educational policy, and multidisciplinary practice to examine return to school related issues for youth following concussion and to identify gaps between established recommendations and real-world applications. Across national and international guidelines, early return to school with symptom-limited cognitive activity is consistently endorsed, while prolonged cognitive rest and delayed academic re-entry are no longer supported. Additionally, students commonly experience learning, sensory, emotional, and environmental challenges that extend beyond school re-entry alone, especially in secondary settings with greater demand variability, highlighting limitations of narrowly framed "return-to-learn" (RTL) and "return-to-school" (RTS) models. Evidence indicates that concussion-related school difficulty reflects an interaction among personal factors such as symptom burden and cognitive endurance, with medical guidance, environmental demands, and institutional constraints, with older students potentially facing disproportionate challenges. Although multidisciplinary care models-including school-based teams, rehabilitation providers, and mental health and medical professionals-are widely recommended, operational guidance for role delineation, communication, and accommodation fidelity remains limited, oftentimes resulting in delays in implementation. As a result, practices related to returning students to the academic environment vary widely across schools and jurisdictions, contributing to inequitable access to effective supports. This review emphasizes the need to facilitate supported return to full school participation rather than solely academic reintegration and outlines practical strategies and research priorities to improve implementation and outcomes.