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Abstract
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Bicycling, snow sports, and other recreational activities and sports are important activities to keep children and youth active as part of a healthy lifestyle. These activities can be associated with serious and fatal head and facial injuries. Helmets, when worn correctly, are effective in decreasing head injuries and fatalities related to these activities. Legislation for helmet use is effective in increasing helmet use in children and, ultimately, in decreasing deaths and head and facial injuries. A multipronged strategy employing legislation, enforcement of laws, and medical clinicians and community programs is important for increasing helmet use to decrease deaths and injuries from recreational sports.
Sport- and recreational activity-related head injuries are a significant cause of death and disability in the pediatric population. Head injuries from sports are contributing to an increasing proportion of all traumatic brain injuries (TBIs) sustained by children and adolescents.1 From 2001 to 2009, emergency department (ED) visits for sport-related TBIs increased 62%, which is estimated to be 248 418 visits annually by patients younger than 19 years.1 The use of helmets has been shown to significantly decrease the risk of nonfatal and fatal head injuries in many sports and recreational activities.2,-5 In addition to head injuries, serious facial injuries can occur during sports and recreational activities. Professional medical organizations, including the American College of Surgeons,6 American Academy of Orthopedic Surgeons,7,8 and American Academy of Pediatrics (AAP),9,10 support helmet use in sports. Additionally, professional sports organizations also advocate for and promote the use of helmets in their sports.11,-14 Although concussions are an important type of head injury, this technical report does not address concussions and their prevention, as this topic is addressed in another AAP clinical report, "Sport-Related Concussion in Children and Adolescents."15 The high incidence of pediatric head injuries and the increasing costs of medical treatment and rehabilitation, as well as lost productivity, reinforce the need for policies and programs to promote helmet use and reduce injury occurrence and severity.16
Epidemiology of Sport-Related Head Injuries
Bicycling
Of all sports and recreational activities, bicycle riding is 1 of the leading causes of head injuries in the pediatric population.1,17,18 Every year, ∼ 26 000 children are seen in EDs for head injuries related to bicycing.19 Of all bicycle-related injuries, TBIs are the most highly associated with mortality.20 There is strong evidence that helmets decrease the risk of head injuries in bicycling as well as reduce overall costs for medical care.21,-24 Nevertheless, studies have found the majority of bicycle riders do not wear helmets consistently.25
Snow Sports
Snow sports, primarily skiing and snowboarding, are among the other leading causes of recreational sport-related head injuries. Between 1993 and 2003, there were an estimated 78 538 snow sports-related head injuries among children and adolescents treated in EDs.26 Head injuries account for 7% to 20% of all injuries related to skiing and snowboarding.27 These injuries are primarily related to falls in which absence of the helmet is associated with an increased risk of TBI.5,27 In an effort to reduce the burden of head injuries, many national snow sport organizations have championed for universal helmet use on slopes.11,-13
Other Recreational Activities
Skating and horseback riding are other activities that contribute to substantial numbers of head injuries in children and adolescents. Of skating-related injuries, ice skating is reported to have the highest percentage of head injuries, with 13% to 20% of all injuries being TBIs.28,29 TBI is also the most common injury encountered in equestrian-related events in patients younger than 18 years, contributing to 14% of all pediatric sports-related injuries.30 Despite the increased risk of TBIs without the use of helmets, rates of consistent helmet use in all forms of skating and horseback riding in children remain low.29,-32
Helmet Effectiveness
The real-world effectiveness of helmets has been best studied in bicyclists. A Cochrane review of the protective effect of bicycle helmets based on 5 studies from different countries concluded that helmets decreased the risk of head, brain, and severe brain injury by 63% to 88% for all ages of bicyclists. The review concluded that bicycle helmets meeting national and international standards provide substantial protection to bicyclists of all ages from various types of crashes, including with motor vehicles.16 Similar protective effects of helmets against bicycle related head and facial injuries have been reported in 2 more recent meta-analyses.4,33
Although helmets are known to be protective from head injuries in sports, it has also been postulated that wearing a helmet could increase cervical spine injuries in children because of the concern that head-neck-helmet biomechanics from the helmet weight could potentially exert forces on the neck, increasing the risk of injury.34 For snow sports (eg, skiing or snowboarding), 1 meta-analysis reported in their pooled analysis that helmets decreased the risk of head injury by 35% (odds ratio [OR]: 0.66; 95% confidence interval [CI]: 0.55 to 0.79; heterogeneity: 75.7%), with no increases in the risk of neck injury.35 Two meta-analyses of bicycle helmet effectiveness reported no increased risk of cervical spine injury with helmet use...
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