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Several young football players died while playing the sport so far this year, raising the perpetual question of whether football is safe for kids.

Seven middle and high school students while playing the sport -- two of them after hits that caused head injuries. Others died from heat, cardiac, or other medical emergencies.

Last year, died from football-related injuries, including one youth league death, according to the National Center for Catastrophic Sport Injury Research (NCCSIR) at the University of North Carolina Chapel Hill.

Most deaths were among high school and college players. Three of those deaths were due to traumatic injury, while 10 were exertional/medical, the report stated.

Focus on Head Trauma

Those traumatic injuries have been the focus of concern, as football is responsible for the highest number of traumatic brain injury (TBI)-related emergency department visits for sports-related injuries in kids, according to Jill Daugherty, PhD, an epidemiologist on the TBI team at the CDC.

A showed that a quarter of ED visits among kids for sports-related TBI are due to football, Daugherty told MedPage Today in an email, adding that tackling is responsible for about two-thirds of concussions and other TBIs among high school football players.

Chris Nowinski, PhD, co-founder and CEO of the Concussion Legacy Foundation, in Boston, a non-profit advocacy organization that collects data on concussions and chronic traumatic encephalopathy (CTE) in athletes, said about 5% of youth football players are diagnosed with concussions each year.

However, many concussions in youth football players go undiagnosed because methods for identifying concussion used at the college and professional level -- such as having physicians on the sidelines -- "can't be done at the youth level," he said.

The risk of head impacts for youth players cannot be overstated, Nowinski said.

"Is it safe to hit a kid in the head 200 times?" he told MedPage Today, noting a found that the median number of head impacts in a season is 378 for 9- to 12-year-old kids. Recent research showed CTE is correlated to the number and strength of repetitive head hits people take over their lifetime, he added.

"If you only played a year or two of football, your risk of CTE is going to be low," said Nowinski, who wrote the Head Games: Football's Concussion Crisis. "The kids who start young and are successful are in big trouble."

Changing the Game

Changes to how youth football is played have been made over time, with a focus on reducing head impacts, Daugherty said. Several athletic organizations -- including the National Federation of State High School Associations -- have implemented new guidelines that restrict the amount and frequency of full-contact practices, she added.

For instance, extreme tackling exercises -- like the -- have been banned at every level of football, Andy Peterson, MD, a team physician for the University of Iowa football program, told MedPage Today.

"The way people practice, discouraging excess contact during practice, that's really changed a lot in the sport, and some of that has been cultural [because] coaches want to keep their players healthy," said Peterson, who is also a member of the American Academy of Pediatrics' Council on Sports Medicine and Fitness.

USA Football has also promoted its program, which aims to certify coaches and calls for teams to have a coach focused on player safety.

Daugherty noted that flag football, where games are played without blocking and tackling, has grown in popularity as participation has declined in tackle football, according to .

Nowinski agreed that "the greatest change we can make to prevent CTE and concussions is flag [football] until 12 or 14 [years old], and the next greatest thing is don't hit in practice."

"Everything else is small," Nowinski added.

However, Peterson said there's that the rate of concussion is similar for both flag and tackle football.

He believes football of any kind is "safer than a lot of the alternatives," such as jumping on trampolines or swimming in backyard pools. He also believes "the benefits of sport participation in general outweigh the risks of sports participation," even for football.

Still, he thinks a developmental model of football -- one that starts kids in flag before progressing to tackling and blocking elements -- would be a safer approach to youth football, allowing young kids to develop the skills of football without being exposed to the cumulative risk of head impacts.

"Most of those cases, most of what we're seeing in these brain bank studies are from people with very long playing careers," Peterson said. "The vast majority of people that seem to be developing [CTE] are people that essentially got hit in the head for a living."

Ensuring Safe Play

A.J. Duffy III, MS, ATC, PT, president of the National Athletic Trainers' Association (NATA), said the key to making youth football safer is to ensure a child's caretakers – parents, coaches, and physicians – understand the risks and how to mitigate them.

First, the youth football player needs to understand that playing football can lead to injury, including head injury, Duffy said. Their parents should also make sure they understand the unique risks for their child, such as whether they have conditions that predispose them to heat-related injury.

Parents should also consult their child's pediatrician on all health risks, if they have concerns, he said. And finally, youth football coaches need to obtain proper education for reducing injury risks for players in practices and in games, Duffy said.

Parents and coaches can minimize other serious risks as well, such as altering practice schedules to avoid dangerously hot weather, and removing any kid who is feeling overheated during practice or a game, he said.

Regardless of the level of preparation, Duffy said there will still be catastrophic events for kids during football activities, so it's important to have an emergency action plan for how to handle those events when they occur, he said.

Only about 37% of high schools have a medical professional or athletic trainer available for games, he said, warning that someone with appropriate training should be available at all games.

"We're doing our best to get the information out there, so that there's proper medical care for those at all levels," Duffy said.

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