High school tackle football remains the most popular boys' sport in the United States with more than 1 million players each year (National Federation of State High School Associations, 2019), despite increasing evidence that the cumulative effects of exposure to head injury and permanent brain damage are significant and of concern to parents and pediatric providers. During the height of the 2022 football season, a prospective, multisite study was published that reported the intensity of head injury impact exposure in high school football players (Kercher et al., 2022). There is recent evidence that "chronic exposure to head impacts, even without eliciting overt concussion symptoms can trigger neuronal microstructural damage, altered brain activation patterns, and functional alteration" (Kercher et al., 2022, p. 2). A report issued by the National Federation of State High School Associations (2019) suggests that the recent decline in participation and other changes in practice guidelines such as reducing the number of practice days may be attributed to these concerns. However, another study (Stemper et al., 2020) showed that simply reducing the number of practice days may not be effective in minimizing head-impact exposure.

The levels-of-contact system developed by U.S.A. Football (2014), the national governing body over amateur football, holds promise. This five-level guide for drill intensity may be helpful to understand how to best regulate head-impact exposure in high school players. Drill intensity is classified as: 1) "Air" where the player is unopposed with no contact with other players; 2) "Bags" when drills are run against a bag or other soft surface; 3) "Control" which controls the speed of the drill prior to any impact; 4) "Thud" when drills are run at high speed through the moment of contact; and 5) "Live" when drills are run with tackling allowed (U.S.A. Football, 2014). Kercher et al. (2022) conducted a prospective, multisite study over one season with 74 players from three high school teams. A total of 7,312 impacts were recorded with a median of 67 per each player (Kercher et al., 2022). They noted that there is an incremental increase in head impacts within the five-level drill intensity categories. Live drills had a higher cumulative head-impact frequency and air drills had the lowest impact frequency. This was a rigorously designed study in which head impact was measured by a sensor-installed mouthguard that each player wore and then confirmed by recorded video analysis of all practices and games (Kercher et al., 2022). These results are consistent with a study conducted comparing head-impact exposures among 524 male tackle and flag football athletes ages 6 to 14 years (Waltzman et al., 2021). Also using mouthguard sensors, this study recorded 186,239 head impacts during one season. Tackle players sustained 14.7 times more head impacts than the flag football players.

Although data using the U.S.A. Football classification systems are relatively new, findings may lead to a way to decrease the often-permanent life-altering sequelae from high-intensity head impact among adolescent football players. Pediatric nurses can play an essential role in educating parents on how the structure of practices may protect their children from long-term brain damage. Nurses and parents can advocate for safer practices at lower intensity with school nurses, coaches, and athletic programs.

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