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Evidence Based Strategies for Common Clinical Questions

October 2022

Keep Calm and Helmet On 

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Author: Zuri Hudson, DO | Pediatric Resident


Column Editor: Kathleen Berg, MD | Co-Director, Department of Evidence Based Practice | Pediatric Hospitalist, Division of Pediatric Hospital Medicine | Associate Professor of Pediatrics, UMKC School of Medicine 


Unintentional injuries are among the leading causes of death and long-term disabilities for children.1 These injuries encompass traffic injuries, burns, drowning, poisoning, falls, suffocation and sports-related injuries. Sport and recreational activity-related head injuries are a significant cause of traumatic brain injury in the pediatric population, leading to disability or death.2 From 2001 to 2009, an annual average of 248,418 patients ≤19 years of age were treated in emergency departments for traumatic brain injury related to sports and recreational activities.3 

In August of this year the Council on Injury, Violence and Poison Prevention provided a technical report on the importance of helmet use to prevent head injuries. This council, the American Academy of Pediatrics, and many other professional medical organizations support helmet use in sports and activities associated with head trauma. These include bicycling, snow skiing, snowboarding, skating (especially ice skating), skateboarding and horseback riding, among others.1 Helmet use significantly decreases the risk of serious facial injuries and fatal head injuries.3 Of all sports and recreational activities, bicycle riding is one of the leading causes of head injuries in the pediatric population, with approximately 26,000 children seen in emergency departments for head injuries annually. Helmets not only decrease head injury risk, but also reduce medical care costs related to diagnostics, hospitalization and rehabilitative care.4 

A recent systematic review of the protective effect of bicycle helmets concluded that those meeting national standards provide substantial protection to bicyclists of all ages from various crashes, including with motor vehicles. Even with this information, studies have found that most bicycle riders do not wear helmets consistently.5 In children aged 5 to 17 years old, 42% always wear a bicycling helmet, with 31% never wearing a bicycling helmet.6 For helmets to prevent head and facial injuries effectively, they must fit properly and meet safety standards. The helmet should be worn squarely on the top of the head, parallel to the ground, and fit snugly with the chin strap adjusted. There should be two fingers-widths from the eyebrow to the bottom of the helmet and one finger-width under the chin strap.

Reasons cited by survey participants for not wearing a helmet include cost, discomfort and lack of belief in its necessity to prevent injury. Helmet use is significantly decreased among non-White populations, Hispanic populations, and lower-income households. A clear social gradient exists in pediatric experiences of preventable injuries secondary to lack of helmet use.6 

Approaches to increase effective helmet use are plentiful and include legislation, law enforcement, anticipatory guidance from providers, and nationwide educational campaigns. State legislation increases rate of use,1 but only 21 states and the District of Columbia have bicycle helmet laws for children. Neither Missouri nor Kansas currently has such laws.7 With continued variable helmet use and increasing preventable injuries, schools, primary care clinics and emergency departments have initiated local helmet-focused injury prevention programs.1 Our responsibility as providers is to educate children of all ages and their families about injury prevention, including correct and consistent helmet use. 

Quick tips to improve your patients’ helmet use: 

  • Encourage parents to wear helmets to model safe behavior for their children. 
  • Start at a young age. 
  • Decorate children’s helmets. Make it fun, bonus points for reflective stickers! 
  • Make it part of a routine, like putting on closed-toed shoes when playing outside. 
  • Leverage their friends, siblings, coaches and even celebrities to model helmet use. Helmets are cool!  


Properly fitting helmets can prevent thousands of pediatric traumatic brain injuries and facial injuries each year. Adult helmet use is associated with increased, appropriate child helmet use.6 Though there are inequities related to barriers and accessibility in helmet use, counseling in multiple settings can decrease unintentional injuries for all children and adolescents. Helmets save lives for both our patients and their parents. Let’s do our part to help protect noggins this fall! 



  1. Lee LK, Flaherty MR, Blanchard AM, Agarwal M; The Council on Injury, Violence, and Poison Prevention. Helmet use in preventing head injuries in bicycling, snow sports, and other recreational activities and sports. Pediatrics. 2022;150(3):e2022058878. doi:10.1542/peds.2022-058878 
  2. Bandte A, Fritzsche FS, Emami P, Kammler G, Püschel K, Krajewski K. Sport-related traumatic brain injury with and without helmets in children. World Neurosurg. 2018;111:e434–e439. 
  3. Gilchrist J, Thomas KE, Xu L, McGuire LC, Coronado V. Nonfatal traumatic brain injuries related to sports and recreation activities among persons aged 19 years–United States, 2001-2009. MMWR Morb Mortal Wkly Rep. 2011;60(39):1337-1342. 
  4. Bicycle, skate and skateboard safety fact sheet (2016). Safekids Worldwide. Accessed August 30, 2018. 
  5. Bou-Karroum L, El-Jardali F, Jabbour M, et al. Preventing unintentional injuries in school-aged children: a systematic review. Pediatrics. 2022;149(suppl 6):e2021053852J. 
  6. Jewett A, Beck LF, Taylor C, Baldwin G. Bicycle helmet use among persons 5 years and older in the United States, 2012. J Safety Res. 2016;59:1-7. 
  7. Bicycle helmet use laws. Insurance Institute for Highway Safety. Accessed September 28, 2022.