Emergency Department Visits for Sports- and Recreation-Related Traumatic Brain Injuries Among Children — United States, 2010–2016

Kelly Sarmiento, MPH; Karen E. Thomas, MPH; Jill Daugherty, PhD; Dana Waltzman, PhD; Juliet K. Haarbauer-Krupa, PhD; Alexis B. Peterson, PhD; Tadesse Haileyesus, MS; Matthew J. Breiding, PhD


Morbidity and Mortality Weekly Report. 2019;68(10):237-242. 

In This Article


Across the 7-year study period, an estimated 2 million children aged <18 years visited an ED because of a TBI sustained during SRR activities. A previous report found a sharp increase from 2006 to 2012 in the rate of SRR-TBI ED visits.[4] Results from the current study suggest there has been a leveling off of overall SRR-TBI ED visits since the last report and a significant decline for males since 2012. Going forward, surveillance for TBI should explore these changes in the SRR-TBI ED visit trends to help develop ongoing and future prevention strategies. Potential reasons for this decline in males might include successful prevention efforts (e.g., safety-minded rule changes in contact sports), reduced participation in contact sports, or changes in care-seeking behaviors.

In all study years, males had approximately twice the rate of SRR-TBI ED visits as did females, which is consistent with other studies suggesting that males are at higher risk.[4,7] SRR-TBI rates also generally increased with age, with children aged 10–14 and 15–17 years having the highest rates SRR-TBIs. These results are likely associated with greater participation of males and older children in contact sports.

Children participating in any SRR activity are at risk for TBI, and earlier studies found higher rates of TBI in sports in which collisions among athletes are more common, such as in football, soccer, basketball, lacrosse, ice hockey, and wrestling.[7] Consistent with those studies, this report found that contact sports resulted in nearly twice as many TBI ED visits as did noncontact sports and four times those associated with recreation-related activities. Preparticipation athletic examinations are an important opportunity for health care providers to identify athletes who might be more susceptible to a TBI and prolonged recovery (such as older children/adolescents and persons with a history of previous TBI or intracranial injury, learning difficulties or lower cognitive ability, neurologic or psychiatric disorder, lower socioeconomic status, and family and social stressors)[8] and to discuss sports-specific injury prevention strategies. In addition, promoting prevention strategies in sports, including limiting player-to-player contact and rule changes that reduce risk for collisions is critical to preventing TBIs.[8] Further research on the impact of strict officiating, state policies, and presence of athletic trainers in preventing sports-related TBI might be beneficial.[8]

CDC published an evidence-based guideline on the diagnosis and management of pediatric mild TBI, including concussion, in 2018.[1] Five important recommendations in the CDC Pediatric Mild TBI Guideline include 1) not routinely imaging pediatric patients to diagnose mild TBI; 2) using validated, age-appropriate symptom scales to diagnose mild TBI; 3) assessing for risk factors for prolonged recovery; 4) providing patients with instructions on returning to activity customized to their symptoms; and 5) counseling patients to return gradually to nonsports activities after no more than 2–3 days of rest. To help implement these recommendations, CDC created educational tools that are available at https://www.cdc.gov/HEADSUP.

The findings in this report are subject to at least five limitations. First, injury rates for specific activities could not be calculated because of a lack of national participation and exposure data. Therefore, the estimates cannot be used to calculate the relative risks for TBI associated with any particular SRR activity. Second, NEISS-AIP includes only injuries resulting in visits to hospital EDs. Research suggests that many children with a TBI do not seek care in EDs or do not seek care at all, resulting in a significant underestimate of prevalence.[9] Third, because NEISS-AIP includes only the principal diagnosis and primary body part recorded during the initial injury visit, some cases for which TBI was a secondary diagnosis (for example, skull fractures, which often have a co-occurring TBI diagnosis) might have been missed. Fourth, NEISS-AIP narrative descriptions do not provide detailed information about injury circumstances (e.g., whether the activity was organized, whether the injury occurred during practice or competition, or whether protective equipment was used). Finally, the available data do not allow for assessment of whether any observed differences in the number of ED visits resulted from a true change in incidence, care-seeking behaviors, or other reasons.

TBIs in sports and recreational activities remain a significant public health problem. Limiting player-to-player contact and rule changes that reduce risk for collisions are critical to preventing TBI in contact and limited-contact sports. Development and testing of evidence-based interventions tailored for individual noncontact sports and recreation activities are warranted to ensure that children can stay healthy and active.