Without a doubt, soccer remains the national pastime of the USA. Football is a contact sport. In combat sports such as boxing, where the goal is to win by causing a knockout (eg a head injury), in football, helmet-to-helmet and helmet-to-turf contact is not intentional. However, due to the nature of sports, head impact exposures (HIE) leading to concussions and sometimes a more severe degree of traumatic brain injury (TBI) unfortunately do occur. Traumatic subdural hematoma is a well-known cause of mortality in combat and contact sports.

Separate from the acute neurological injuries reported in the game, the burden of chronic Neurological injuries—such as chronic post-concussion symptoms, post-traumatic parkinsonism, post-traumatic cognitive deficits, mood and behavioral changes, and chronic traumatic encephalopathy (CTE)—are gaining increased attention from the sports medicine community. The burden is probably greater than known because it remains hidden for years or even decades — it comes into focus long after the player has stopped playing, usually in their 40s or 50s.

But what about when these chronic injuries start in childhood? Given the popularity of soccer, young people are often exposed to the game at a young age. In America, the age at which children start playing soccer varies. In high school, soccer is the norm, and kids can start playing around the age of 14-15. However, some secondary schools also offer tackle football. Others stick to flag football.

High school football remains extremely competitive. Being dinged is common. Unfortunately, there have been a number of recently reported deaths among youth and high school football players, which has raised renewed concern about the health hazards of concussive brain injury to the pediatric brain. Age susceptibility to concussive head injury is well recognized: the young (pediatric) brain is more susceptible to the adverse effects of HIE compared to the adult brain.

While contact sports like football can’t be made completely safe, they can be made safer — especially for young people. This goal will require a collective effort from all parties involved.

While a blanket ban on youth football is neither a practical nor viable solution, I believe it would be prudent for each school or youth football program to consider and implement the following where one or all of these rules are not already in force:

The game of football should be age-restricted: Children should play flag football until they are at least 14-15 years old.

It makes no sense to be swallowed up in practice: All youth and high school football practice sessions should be limited to flag football. As the athlete matures in both age and football skills, tackle football should be introduced with an emphasis on learning the correct techniques to defend against an accidental kick.

Appropriate medical supervision: The NFL has instituted strict concussion protocols. These include the sideline presence of the team doctor and athletic trainers. Athletic trainers undergo concussion recognition and management training. In addition, with each game, there is at least three unaffiliated neurotrauma consultants (UNC). These UNCs are either neurologists, neurosurgeons, or emergency physicians highly skilled in the recognition and management of concussion.

There is a UNC stationed at both the home and away 25 yard lines. The third UNC is stationed in the cabin next to the athletic trainer (ATC) observer. An ATC spotter is a certified athletic trainer who monitors the game closely to identify injuries and communicates the same to the referee or medical staff. While this level of medical supervision may not be logistically feasible at every youth and high school football game, all games should have at least one physician on the sidelines.

It should be mandatory for all coaches to be certified in concussion recognition and management. Additionally, each game should always have at least one ambulance present along with emergency medical service (EMS) personnel. The minimum equipment that should be available on the sideline includes a panel, cervical collar, splints, oxygen, endotracheal intubation equipment, and an automated external defibrillator.

Protective items: It should be mandatory for all players to wear a high quality certified helmet with a well fitting mouthpiece. The use Guard caps should be encouraged.

Strict application of concussion protocols after HIE: After a player suffers HIE and displays symptoms and signs of concussion — such as headache, subjective feeling of dizziness, sensitivity to light, sensitivity to sound, confusion or gross motor instability — they should be immediately removed from the game and be given a concussion evaluation either on the sideline or in the locker room. An athlete with a concussion should enter the concussion protocol. While the player is undergoing the concussion “return to play” protocol, he should remain under the close observation of coaches and athletic trainers. He should be evaluated by a neurologist or sports medicine physician skilled in concussion recognition and management before clearance to return to play.

Education remains the key: All parties involved should be educated on the recognition and management of concussion. This includes youth players, coaches, athletic trainers and parents.

Culture change: The culture of youth and high school football needs to change from one of “shake it off and keep playing” to one of “if you feel something, say something and stay out.”

Monitoring: There should be stricter monitoring of the brain health of these young athletes. Serial neuroimaging and neurocognitive assessments can help accomplish this. If worrisome neuroimaging changes or a decline in neurocognitive scores are observed, the player should be advised to stop playing.

Changes to the rules: Consideration should be given to changing the rules of the game to avoid dangerous tackles. This would require the involvement of all stakeholders, including the sport’s governing bodies.

Making youth soccer safer requires a collective effort from all parties involved. In no sport should an athlete die — especially not children, and especially not on a regular basis. Football should be no different.

Nitin K Sethi, MD, MBBS, is an associate professor of neurology at New York-Presbyterian Hospital/Weill Cornell Medical Center. It now serves as a voluntary faculty.