Cardiac events are responsible for most deaths in youth athletes. According to a new study by the National Athletic Trainer’s Association, the vast majority of youth athletes who suffer sudden cardiac-related deaths while playing sports are middle schoolers.

Researchers analyzed 45 sudden sports deaths that happened between 2007 and 2015. Each of the deaths occurred among children between the ages of six and 17.

Sudden cardiac events such as heart attacks were responsible for 76% of the deaths. However, most deaths involved athletes between the ages of 12 and 14 regardless of the cause or injury.

Up to 36% of sudden youth sports deaths occurred in basketball. Baseball accounted for 16% of deaths, football also accounted for 16% of deaths, and soccer accounted for 13%.

Researchers found that two-thirds of sudden cardiac-related deaths occurred during practice. However, whether students were using cardio equipment or strength equipment wasn’t during practice wasn’t revealed.

It also wasn’t determined whether athletes were more likely to suffer cardiac events on hotter days. The sun’s rays are strongest between 10 AM and 2 PM, and physical activity on warm or hot days can increase the body’s core temperature.

Dr. David Siphon, the director of preventative sports cardiology at Jefferson Health, suggests the reason for these high death rates among middle school athletes is because students don’t complete a sports physical.

States require that high school athletes complete a sports physical with their medical care provider before they begin participating in school sports. But that’s not the case with middle school.

Standards tend to be laxer when it comes to athletes at younger ages because experts believe the risk of cardiac arrest is higher among high school and college athletes.

“This article puts that into question,” said Shipon. “Is it truly higher risk or is it that we never really had the true data?”

Shipon says more research and better databases are necessary to get a better understanding of the situation. There isn’t a streamlined database that documents sudden deaths among youth student-athletes. The researchers in the study compiled data by searching for deaths reported by media outlets across the country.

Despite the lack of a database, the study’s findings mirror previous research that was conducted on high school and collegiate athletes. Experts say the findings suggest middle school athletes ought to complete a pre-participation medical exam like high schoolers and college athletes do.

“The issue is that middle school sports have a less structured policy than high school sports when it comes to a pre-participation physical,” Shipon said. “There is less emphasis on this issue, likely because a lot of these kids are playing in recreational sports. They’re playing outside of the school.”

In 2017, the number of participants in tackle football aged six years and older was 5.22 million While approximately 58% of sudden deaths happened in organized middle school sports and clubs, another 40% happened in recreational and youth sports leagues.

Dr. Neel Chokshi, the medical director of Penn’s Sports Cardiology and Fitness Program, says screenings can potentially help reduce sudden deaths, but they don’t always identify a predisposition to sudden cardiac arrest.

“The best option is to just be prepared on the really rare instance that such an event would occur,” Chokshi said.

This includes having defibrillators on hand at athletic events and people on hand who are trained in how to use them and in CPR. NATA and the National Basketball Athletic Trainers Association have also released a list of recommendations that could help to prevent future sports-related deaths.

Advancements in heart health and medicine have come a long way since the cardiopulmonary bypass was developed in 1953. Now, school and youth sports leagues must change their attitudes with the times.