By James Wright, MD, MPH, FRCSC
Sports and recreational activities are important for children’s health and development. They also carry a risk of injury: according to Safe Kids Canada, nearly 20% of children’s emergency room visits are due to sports and recreation injuries. Fortunately, sports are one area where injuries, and especially head injuries, can be reduced or prevented by using the right equipment.
We are still learning about the long-term effects of head injury. Severe head injury can cause disability or death.
In 1999, according to statistics from the Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP), 43% of injured children aged five to nine and nearly one-quarter of injured children aged 10 to 19 had a head injury. Obviously, not all of these head injuries were related to sports, and not all of them could have been prevented. But in many cases, a helmet can make all the difference between serious injury and walking away from an accident unharmed.
Do helmets work?
Some sports, such as bicycling, hockey, and horseback riding, carry a high risk of head injury. There is good evidence that the right helmet can protect against head injury in these sports.
Bicycling
The effect of bicycle helmets on injury rates has been widely studied in both adults and children. Bicycle helmets have been shown to reduce the risk of head, brain, and facial injury, in some cases dramatically: a systematic review of five case-control studies found that helmets reduced the risk of head and brain injury by up to 88%. As might be expected, though, helmets are not always able to protect against injury to the lower face and teeth.
Studies from New Zealand and Canada have shown that helmet legislation is associated with a reduction in bicycle-related head injuries. By law, children must wear bicycle helmets in Ontario and Alberta, and bicyclists of all ages must wear helmets in Prince Edward Island, Nova Scotia, New Brunswick, Manitoba, and British Columbia. Some cities and towns in other provinces also have helmet by-laws.
Football
Studies in adults have found that a combination of helmet standards and strict rules regarding the use of the head in blocking and tackling has resulted in an 84% reduction in serious head injury since 1976. Other studies suggest that there has also been a reduction in concussion rates among high school football players.
Hockey
Helmets reduce the risk of fatal and serious head injury, and full face guards reduce the risk of eye injury in hockey. There is less evidence that helmets reduce the risk of mild brain injury. Hockey Canada, however, requires all players to wear a CSA-certified helmet with a face protector at all times while they are on the ice.
Horseback riding
Many studies have found that helmets greatly reduce the risk of serious head injury in horseback riding.
Ice skating
A recent study found that ice-skaters were four times more likely to sustain head injuries than in-line skaters, and recommended that ice-skaters wear helmets and other protective equipment.
Off-road and all-terrain vehicles and snowmobiles
Studies have found that the head is often injured in accidents involving all-terrain vehicles or snowmobiles. One recent study found that wearing a helmet significantly reduced the risk of head injury in an ATV accident. Saskatchewan, Ontario, Quebec, New Brunswick, Nova Scotia, Prince Edward Island, and the Yukon require the use of a helmet while driving a snowmobile. All provinces and territories, with the exception of British Columbia, require helmets when driving an ATV.
Rugby
Padded headgear does not appear to protect against concussion in rugby, although it may help to reduce superficial cuts and bruises. One study suggests that rugby players believe they can tackle harder while wearing headgear, which may contribute to the problem.
Skiing and snowboarding
Helmets reduce the risk of severe head injury by up to 56% but have less effect on milder head injury. Some studies have found a potential increase in neck injury when helmets are used in skiing and snowboarding, but others have found no such increase.
Helmets are also recommended for in-line skating, scooters, and go-karts, although their effectiveness has been less studied.
How do helmets work?
When the head hits a hard surface, it stops moving very quickly. This can cause the brain to hit the inside of the skull, and can also damage the connections between brain cells. The surface of the head can also be cut or bruised, especially if it hits a sharp object. In severe cases, the skull may be fractured.
In general, helmets are designed to:
- help the head slow down more gradually
- spread the impact over a larger area
- prevent direct impact to the skull
Different helmets are designed for different sports, and there are correspondingly different standards for them. There may need to be a trade-off between protection, weight, and the person’s ability to see and hear. Some helmets may be designed for a particular impact speed.
Obviously, helmets do not provide a suit of armour, and no helmet can protect against all possible injuries. It’s important to teach children safety skills as well. In contact sports, rules to protect the head and neck are another important part of preventing injury. And, of course, helmets only work if they are worn consistently and correctly.
Choosing a helmet
Children should wear the right helmet for their activity: it is not safe, for example, to wear a bicycle helmet to play hockey, and vice versa. Helmets should be certified by an organization such as the Canadian Standards Association (CSA), the Snell Memorial Foundation (Snell), the American National Standard Institute (ANSI), the American Society for Testing and Materials (ASTMF), the British Standards Institute (BSI), or the Standards Association of Australia (AS).
It’s important that the helmet fit properly, and equally important that the child wear and secure the helmet correctly. Most helmets come with fitting instructions.
If a helmet has been dropped or the child has been in an accident while wearing the helmet, get a new one, even if it seems undamaged. If the child lost consciousness or may have lost consciousness after a head injury, he should see a physician, even if he was wearing a helmet.
Helmet laws and rules
Most provinces and territories have laws requiring that children under 18 wear a helmet when riding a bicycle on a public road. This usually includes bicycle passengers, for example children riding behind a parent. Individual cities and towns may also have their own helmet by-laws.
In general, parents of children under 16 are responsible for making sure that their child wears a helmet, and may face a fine if the law is not obeyed. Children who are 16 and 17 years old are responsible for their own helmets.
Depending on the laws of their province or territory, children may also have to wear a helmet when riding:
- scooters, skateboards, in-line skates, or roller skates
- horses
- off-road and all-terrain vehicles
- snowmobiles and sleds towed by snowmobiles
- motorcycles and mopeds
Sports leagues such as Hockey Canada may also require helmets.
Even where no law specifies helmet use, parents must ensure their children wear helmets. Head injury can result in life-long disability. Helmets are a simple, proven way to prevent possible tragedies and provide peace of mind.
Dr. James G. Wright, MD, MPH, FRCSC, is Surgeon-in-Chief, Robert B. Salter Chair of Pediatric Surgical Research, and Senior Scientist, Population Health Sciences at The Hospital for Sick Children (SickKids). He is also a professor in the Departments of Surgery, Public Health Sciences, and Health Policy, Management, and Evaluation at the University of Toronto.
Surgeon's Corner columns by James G. Wright