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Abstract
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Recreational activities and sports are a common and popular way for youth to enjoy physical activity; however, there are risks related to physical injury. Injuries can potentially result in death and long-term disability, especially from traumatic brain injury. Helmet use can significantly decrease the risk of fatal and nonfatal head injury, including severe traumatic brain injury and facial injuries when participating in recreational sports. The most robust evidence of helmet effectiveness has been demonstrated with bicycling and snow sports (eg, skiing, snowboarding). Despite this evidence, helmets are not worn consistently with all recreational sports. A multipronged approach is necessary to increase helmet use by children and youth participating in recreational sports. This approach includes legislation and enforcement, public educational campaigns, child education programs, and anticipatory guidance from clinicians. This policy statement guides clinicians, public health advocates, and policymakers on best practices for increasing helmet use in recreational sports, including bicycling and snow sports.
Recreational sports and physical activities continue to increase in popularity, with an estimated 218.5 million United States residents older than 6 years engaging in these activities in 2018.1 The benefits of sports for youth are well established2,3; nonetheless, there are risks related to physical injuries, including morbidity and mortality from traumatic brain injuries (TBIs). Injury rates from recreational sports among participants 5 years and older are highest for children 5 through 14 years of age (76.6/1000 persons) and youth 15 through 24 years of age (55.6/1000 persons).4 Sports-related activities account for an increasing proportion of TBIs.5 Children and adolescents engage in a variety of recreational activities using motorized and nonmotorized, wheeled devices, as well as engaging in nonwheeled activities. Some recreational sports associated with risks for head injuries include bicycling,6,7 skiing and snowboarding (henceforth collectively termed "snow sports"),8 ice skating,9 and equestrian sports.10 All-terrain vehicles are addressed in a separate policy statement and technical report, currently in development.
Serious head injuries, including TBIs, from recreational sports can often be prevented or the injuries can be mitigated. Helmet use in sports and recreational activities significantly decreases the risk of nonfatal and fatal head injuries and facial injuries.10,-14 Despite the strong evidence for the effectiveness of helmets in decreasing head and facial injuries, their use is not consistent among sports participants.10,15,-20 Helmet use is also cost-effective in the prevention of head injuries.21,22 To increase helmet use, a multipronged approach including legislation,23,-25 enforcement of laws and rules,26 public educational campaigns,27 child education programs,28,29 anticipatory guidance from clinicians,30,31 and equitable access to helmets will be required. The purpose of this policy statement is to guide clinicians, public health advocates, and policymakers regarding the evidence-based best practice for helmet use and promotion in recreational sports, including bicycling and snow sports. This policy statement accompanies the technical report, "Helmet Use in Preventing Head Injuries in Bicycling, Snow Sports, and Other Recreational Activities and Sports." Although concussions are an important type of head injury, concussions and their prevention are not addressed here because this topic is addressed in another American Academy of Pediatrics clinical report, "Sport-Related Concussion in Children and Adolescents."32
Bicycle riding is one of the leading causes of sport-related head injuries in pediatrics,5,-7 resulting in an estimated 26 000 emergency department visits annually.33 Snow sports (ie, skiing and snowboarding) are another leading cause of recreational sport-related head injury, and the risk of TBI is increased if the participant is not wearing a helmet.8,13 Among other recreational sports, ice skating9,34 and equestrian sports10 are also associated with risks of head injury.
The effectiveness of helmets in decreasing head and facial injuries has been best studied among bicyclists. A Cochrane review based on 5 international studies reported that helmets decreased the risk of head, brain, and severe brain injury by 63% to 88% for bicyclists of all ages and calculated a summary adjusted odds ratio (OR) of 0.31 (95% confidence interval [CI]: 0.26-0.37).12 Two more recently published meta-analyses reported similar protective effects of helmets against bicycle-related head and facial injuries.35,36
Helmets are also effective in decreasing the risk of head injuries in snow sports. One meta-analysis including 6 studies reported that helmets decreased the risk of head injuries with a pooled OR of 0.58 (95% CI: 0.51-0.77),37 and another based on 9 studies reported a pooled OR for head injury of 0.66 (95% CI: 0.55-0.79).38 The evidence on helmets for decreasing head injuries in other recreational sports (eg, skating, ice skating, nonmotorized wheeled sports) also reports decreased odds for head injury in helmeted compared with unhelmeted children, but the research is more limited.7,20,39,40
To ensure optimal protection against head injury, proper helmet fit is important because multiple sizes are available in the consumer market. For a correct fit, the helmet should be positioned on the head so it sits low on the forehead with the child able to see the brim of the helmet when looking upward. The helmet should sit parallel to the ground when the head is upright and should have any pads adjusted (ie, installed or removed) for a snug fit. The chin strap should be comfortably secure, allowing only 2 fingers aligned side by side to fit between the chin and the strap. The helmet should then be secure enough so it will not come off or move forward over the eyes with shaking of the head.41
Despite the evidence for the effectiveness of helmets in decreasing the risk of head and facial injuries in recreational sports, helmets are not consistently worn. For children 5 through 17 years of age, a 2012 study of United States bicycle helmet use reported that only 42% always wore a helmet, and 31% never wore a helmet.18 A national study of skateboarders and snowboarders younger than 18 years reported that 52% of children injured were unhelemeted.20 Reported reasons for not wearing a helmet when participating in recreational sports include: cost, discomfort, and lack of belief helmets are necessary to prevent injury.42,-45 It is important to note that adult helmet-wearing, younger child age (4 through 12 years old), and female sex have been associated with increased helmet-wearing in children.18,42,44
To increase helmet use and decrease the risk of head injuries in children and youth participating in recreational sports, there is evidence for several effective approaches...
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