Preventing sport-acquired brain damage in children: ‘If in doubt, sit them out’ on its own is not good enough

Concerns for the health problems related to sport-acquired brain damage have grown in recent decades (Malcolm, 2019). Much of this has been associated with impact-sports, defined here as those wherein rapid acceleration or de-acceleration of the brain occurs within the rules of play, thus making brain damage an anticipated consequence of participation. Such damage and subsequent injuries occur most obviously in combat sports, where participants are struck in the head, but also occurs in absence of the head being struck directly, such as during tackling in rugby or being ‘checked’ in ice-hockey.<br/>Brain damage in impact-sports, specifically, has garnered considerable attention amongst medical experts, academics, journalists, activists, athletes and the public, as well as there being ongoing civil litigation against sporting organisations for alleged malpractice (Kilgallon, 2024). While there are various brain health issues associated with impact-sport participation, two that dominate popular discourse are: 1) Traumatic brain injuries (TBI), and 2) Chronic Traumatic Encephalopathy (CTE), a neurodegenerative disease associated with repetitive head impacts.<br/>Within this broad context, there have been limited policy responses from governments and sporting governing bodies in relation to primary prevention of sport-acquired brain damage and injuries. That is, actions that aim to prevent injury, illness and harm before it occurs. For impact-sports, this approach would mean eliminating exposure by removing aspects known to be the cause of TBI, such as the tackle in rugby Hancock et al. (2024). A preventative approach would be the most effective method of reducing TBIs specifically (Cross et al., 2019), and brain damage generally, in impact-sports.<br/>Yet, this approach would threaten what are perceived to be integral parts of these sports and are the source of enjoyment for many (spectators and participants). Primary prevention would also undermine corporate interests through disrupting the professional codes of impact-sports (Piggin et al., 2023). Likely in part because of these points, combined with the often-unquestioned cultural belief that all sport is always straightforwardly ‘healthy’ (Waddington, 2000), many of the organisational actions toward dealing with brain damage have been oriented around secondary and tertiary health care. This approach accepts some level of brain damage as inevitable and therefore actions have mostly focused on: 1) identifying and managing TBIs after they occur, and 2) increasing education on the risks associated with such injuries.