Bicycle helmet laws are associated with a lower fatality rate from bicycle-motor vehicle collisions

Effectiveness of road safety interventions: An evidence and gap map

Background

Road Traffic injuries (RTI) are among the top ten leading causes of death in the world resulting in 1.35 million deaths every year, about 93% of which occur in low- and middle-income countries (LMICs). Despite several global resolutions to reduce traffic injuries, they have continued to grow in many countries. Many high-income countries have successfully reduced RTI by using a public health approach and implementing evidence-based interventions. As many LMICs develop their highway infrastructure, adopting a similar scientific approach towards road safety is crucial. The evidence also needs to be evaluated to assess external validity because measures that have worked in high-income countries may not translate equally well to other contexts. An evidence gap map for RTI is the first step towards understanding what evidence is available, from where, and the key gaps in knowledge.

Objectives

The objective of this evidence gap map (EGM) is to identify existing evidence from all effectiveness studies and systematic reviews related to road safety interventions. In addition, the EGM identifies gaps in evidence where new primary studies and systematic reviews could add value. This will help direct future research and discussions based on systematic evidence towards the approaches and interventions which are most effective in the road safety sector. This could enable the generation of evidence for informing policy at global, regional or national levels.

Search Methods

The EGM includes systematic reviews and impact evaluations assessing the effect of interventions for RTI reported in academic databases, organization websites, and grey literature sources. The studies were searched up to December 2019.

Selection Criteria

The interventions were divided into five broad categories: (a) human factors (e.g., enforcement or road user education), (b) road design, infrastructure and traffic control, (c) legal and institutional framework, (d) post-crash pre-hospital care, and (e) vehicle factors (except car design for occupant protection) and protective devices. Included studies reported two primary outcomes: fatal crashes and non-fatal injury crashes; and four intermediate outcomes: change in use of seat belts, change in use of helmets, change in speed, and change in alcohol/drug use. Studies were excluded if they did not report injury or fatality as one of the outcomes.

Data Collection and Analysis

The EGM is presented in the form of a matrix with two primary dimensions: interventions (rows) and outcomes (columns). Additional dimensions are country income groups, region, quality level for systematic reviews, type of study design used (e.g., case-control), type of road user studied (e.g., pedestrian, cyclists), age groups, and road type. The EGM is available online where the matrix of interventions and outcomes can be filtered by one or more dimensions. The webpage includes a bibliography of the selected studies and titles and abstracts available for preview. Quality appraisal for systematic reviews was conducted using a critical appraisal tool for systematic reviews, AMSTAR 2.

Main Results

The EGM identified 1859 studies of which 322 were systematic reviews, 7 were protocol studies and 1530 were impact evaluations. Some studies included more than one intervention, outcome, study method, or study region. The studies were distributed among intervention categories as: human factors (n = 771), road design, infrastructure and traffic control (n = 661), legal and institutional framework (n = 424), post-crash pre-hospital care (n = 118) and vehicle factors and protective devices (n = 111). Fatal crashes as outcomes were reported in 1414 records and non-fatal injury crashes in 1252 records. Among the four intermediate outcomes, speed was most commonly reported (n = 298) followed by alcohol (n = 206), use of seatbelts (n = 167), and use of helmets (n = 66). Ninety-six percent of the studies were reported from high-income countries (HIC), 4.5% from upper-middle-income countries, and only 1.4% from lower-middle and low-income countries. There were 25 systematic reviews of high quality, 4 of moderate quality, and 293 of low quality.

Authors' Conclusions

The EGM shows that the distribution of available road safety evidence is skewed across the world. A vast majority of the literature is from HICs. In contrast, only a small fraction of the literature reports on the many LMICs that are fast expanding their road infrastructure, experiencing rapid changes in traffic patterns, and witnessing growth in road injuries. This bias in literature explains why many interventions that are of high importance in the context of LMICs remain poorly studied. Besides, many interventions that have been tested only in HICs may not work equally effectively in LMICs. Another important finding was that a large majority of systematic reviews are of low quality. The scarcity of evidence on many important interventions and lack of good quality evidence-synthesis have significant implications for future road safety research and practice in LMICs. The EGM presented here will help identify priority areas for researchers, while directing practitioners and policy makers towards proven interventions.

Helmet Use in Preventing Head Injuries in Bicycling, Snow Sports, and Other Recreational Activities and Sports

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.

Helmet Use in Preventing Head Injuries in Bicycling, Snow Sports, and Other Recreational Activities and Sports

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.

Analyzing pediatric bicycle injuries using geo-demographic data

PURPOSE

Bicycle accidents are potentially preventable, and helmets can mitigate the severity of injuries. The purpose of the study it to investigate geo-demographic areas to establish prevention policies and targeted programs.

METHODS

From October 2013 to March 2020 all bicycle injuries at a Level 1 trauma center were collected for ages ≤18 years. Demographics, injuries, and outcomes were analyzed. Incidents were aggregated to zip codes and the Local Indicators of Spatial Association (LISA) statistic was used to test for spatial clustering of injury rates per 10,000 children.

RESULTS

Over the 8-year time period, 77 cases were identified with an average age of 13±4 years, 83% male and 48% non-Hispanic white. The majority of patients (98%) were not wearing a helmet. Loss of consciousness was reported in 44% and 21% sustained a traumatic brain injury. Twenty-eight percent required ICU care and 36% required operative interventions. There was only 1 mortality in the cohort (<1%).Injuries were more common in lower household income zip codes (Figure 1). Six zip codes encompassing several interstate exits and the connected heavy-traffic roadways comprise a statistically significant cluster of pediatric bicycle accidents (Figure 1).

CONCLUSION

Low-income neighborhoods and those near major roadways held the highest risk for pediatric bicycle accidents. Use of helmets was extremely low in the patient population, with high rates of traumatic brain injury. With this information, targeted programs to address high-risk intersections, helmet access, and safety education can be implemented locally.

A taxonomy of childhood pedal cyclist injuries from latent class analysis: associations with factors pertinent to prevention

BACKGROUND

Studies of pedal cyclist injuries have largely focused on individual injury categories, but every region of the cyclist's body is exposed to potential trauma. Real-world injury patterns can be complex, and isolated injuries to one body part are uncommon among casualties requiring hospitalization. Latent class analysis (LCA) may identify important patterns in heterogeneous samples of qualitative data.

METHODS

Data were taken from the Trauma Quality Improvement Program of the American College of Surgeons for 2017. Inclusion criteria were age 18 years or less and an external cause of injury code for pedal cyclist. Injuries were characterized by Abbreviated Injury Scale codes. Injury categories and the total number of injuries served as covariates for LCA. A model was selected on the basis of the Akaike and Bayesian information criteria and the interpretability of the classes. Associations were analyzed between class membership and demographic factors, circumstantial factors, metrics of injury severity, and helmet wear. Within-class associations of helmet wear with injury severity were analyzed as well.

RESULTS

There were 6151 injured pediatric pedal cyclists in the study sample. The mortality rate was 0.5%. The rate of helmet wear was 18%. LCA yielded a model with 6 classes: 'polytrauma' (5.5%), 'brain' (9.0%), 'abdomen' (11.0%), 'upper limb' (20.9%), 'lower limb' (12.4%), and 'head' (41.2%). Class membership had highly significant univariate associations with all covariates except insurance payer. Helmet wear was most common in the 'abdomen' class and least common in the 'polytrauma' and 'brain' classes. Within classes, there was no association of helmet wear with severity of injury.

CONCLUSIONS

LCA identified 6 clear and distinct patterns of injury with varying demographic and circumstantial associations that may be relevant for prevention. The rate of helmet wear was low, but it varied among classes in accordance with mechanistic expectations. LCA may be an underutilized tool in trauma epidemiology.

To helmet or not to helmet: a global perspective on the bicycle compulsory protective helmet law

Child injury from bike accidents is a significant component of morbidity, mortality and health expenditure in many countries. Universal use of bicycle helmets by children could prevent between 135 and 155 deaths, and between 39,000 and 45,000 head injuries annually. Surprisingly, epidemiologic data indicate a worldwide low prevalence of helmet use. A global view on the law on the compulsory use of safety helmets involving 58 different countries is provided in order to bring this critical debate back to the table. A broad search using "bicycle-related injuries," "bicycle helmet," "bicycle helmet legislation" and "compulsory bicycle helmet law by countries" was performed in order to identify and select the most pertinent information on the issue as well as all the information available on bicycle helmet law by countries. The papers identified permitted us to assess the main topics related to the use of bicycle helmets discussed over the years which are still relevant and without consensus even today, as well as alphabetically enlist the approach of 58 countries to the compulsory helmet law. Our review on the many faces of the bicycle helmet use (pros and cons), personal aspects, head injuries, legislation, promotion, socioeconomic influence, and finally a global view on the law on the compulsory use of safety helmets allowed us to bring here many suggestions and a few conclusions, mainly because "to helmet or not to helmet" should not be a question anymore. A universal consensus on their compulsory use has to be achieved in order to improve children's safety.

Bike helmets prevent pediatric head injury in serious bicycle crashes with motor vehicles

BACKGROUND

Approximately 75% of all bicycle-related mortality is secondary to head injuries, 85% of which could have been prevented by wearing a bicycle helmet. Younger children appear to be at greater risk than adults, yet helmet use is low despite this risk and legislation and ordinances requiring helmet use among younger riders. We sought to determine whether bicycle helmets are associated with the incidence and severity of head injury among pediatric bicyclists involved in a bicycle crash involving a motor vehicle.

METHODS

We performed a retrospective review of patients age ≤ 18 years hospitalized at a level I pediatric trauma center between January 1, 2008, and December 31, 2018. Data were abstracted from the institutional trauma registry and electronic medical record. International Classification of Diseases 9th and 10th editions and external causes of injury codes were used to identify MV related bicycle crashes and determine the abbreviated injury severity (AIS) for head injury severity. Injury narratives were reviewed to determine helmet use. We calculated the incidence of head injury from bicycle vs. MV crashes utilizing descriptive statistics. We analyzed the risk and severity of injury utilizing univariate and multivariate logistic regression.

RESULTS

Overall, 226 bicyclists were treated for injuries from being struck by a MV. The median age was 11 (interquartile range (IQR): 8 to 13) years. Helmeted bicyclists (n = 26, 27%) were younger (9.4 years versus 10.8 years, p = 0.04), and were less likely (OR 0.21, 95% CI 0.09 to 0.49) to be diagnosed with a head injury compared to unhelmeted bicyclists (n = 199). Of those with a head injury, helmeted bicyclists were less likely (OR 0.57, 95% CI 0.11-2.82) to sustain severe or higher injury using AIS. When adjusting for demographics (age, sex, race) and injury severity, helmet use predicted a reduction in head injury (OR 6.02, 95% CI 2.4-15.2).

CONCLUSIONS

Bicycle helmet use was associated with reduced odds of head injury and severity of injury.. These results support the use of strategies to increase the uptake of bicycle helmets wearing as part of a comprehensive youth bicycling injury prevention program.

Primary prevention of road traffic accident-related traumatic brain injuries in younger populations: a systematic review of helmet legislation

OBJECTIVE

Road traffic accidents are the most frequent cause of severe traumatic brain injury (TBI), particularly among young populations worldwide. Helmets are proven to prevent injuries; however, estimates of helmet compliance are low globally. Surgical/critical care management of TBI is often used to treat these injuries, but primary prevention should be recommended. A key component in promoting TBI prevention among pediatric and young populations is through helmet legislation. The authors investigated helmet policies for motorcycles and bicycles globally to provide recommendations for how related legislation may impact TBI and guide advocacy in pediatric neurosurgery.

METHODS

The authors conducted a systematic review of helmet laws and/or policies by using the National Library of Medicine PubMed and SCOPUS databases. Additional articles were identified using citation searches of key publications. Abstracts from articles of all sources were read and selected for full-text review. Details of relevant full articles were extracted and analyzed for the following: bibliographic data, study aim, design and duration, study participants, intervention characteristics, and intervention effect data.

RESULTS

Of 618 search results, 53 full-text articles were analyzed for recommendations. Helmet legislation is associated with increased helmet use among bicyclists and decreased road traffic accident-related head injuries and fatalities among motorcyclists and bicyclists. Laws are more effective if comprehensive and inclusive of the following: both primary riders and passengers, all age groups, all modes of transportation made safer by helmets, a proper use clause, and standardized helmet quality measures. Cultural, socioeconomic, and infrastructural circumstances are important as well, and legislation must consider enforcement mechanisms with penalties significant enough to incentivize behavioral changes, but proportional to community socioeconomic status.

CONCLUSIONS

Compulsory use laws are the optimal primary intervention; however, concurrent programs to support financial access to helmets, change cultural attitudes, increase health literacy, and improve road infrastructure will augment legislative benefits. Pediatric neurosurgeons are caretakers of children suffering from TBI. Although extensive study has explored the surgical management of TBI, the authors believe that primary prevention is instrumental to improving outcomes and reducing injury. All helmet laws are not equal; based on these findings, a comprehensive, context-specific approach is the key to success, especially in resource-limited countries.

Preventing injuries must be a priority to prevent disease in the twenty-first century

Injuries continue to be the leading cause of morbidity and mortality for children, adolescents, and young adults aged 1-24 years in industrialized countries in the twenty-first century. In this age group, injuries cause more fatalities than all other causes combined in the United States (U.S.). Importantly, many of these injuries are preventable. Annually in the U.S. there are >9 million emergency department visits for injuries and >16,000 deaths in children and adolescents aged 0-19 years. Among injury mechanisms, motor vehicle crashes, firearm suicide, and firearm homicide remain the leading mechanisms of injury-related death. More recently, poisoning has become a rapidly rising cause of both intentional and unintentional death in teenagers and young adults aged 15-24 years. For young children aged 1-5 years, water submersion injuries are the leading cause of death. Sports and home-related injuries are important mechanisms of nonfatal injuries. Preventing injuries, which potentially cause lifelong morbidity, as well as preventing injury deaths, must be a priority. A multi-pronged approach using legislation, advancing safety technology, improving the built environment, anticipatory guidance by clinical providers, and education of caregivers will be necessary to decrease and prevent injuries in the twenty-first century.

Adoption of municipal bylaw legislating mandatory helmet use for cyclists under the age of 18: impact on cycling and helmet use

INTRODUCTION

Bicycle helmet use is recognized as an effective way to prevent head injuries in cyclists. A number of countries have introduced legislation to make helmets mandatory, but many object to this type of measure for fear that it could discourage people, particularly teenagers, from cycling. In 2011, the City of Sherbrooke adopted a bylaw requiring minors to wear a bicycle helmet. The objective of this study was to assess the impact of this bylaw on cycling and bicycle helmet use.

METHODS

The impact of the bylaw was measured by comparing the evolution of bicycle helmet use among youth aged 12 to 17 years in the Sherbrooke area (n = 248) and in three control regions (n = 767), through the use of logistic regression analyses.

RESULTS

Cycling rates remained stable in the Sherbrooke area (going from 49.9% to 53.8%) but decreased in the control regions (going from 59.1% to 46.3%). This difference in evolution shows that cycling rates increased in the Sherbrooke area after the adoption of the bylaw, compared to the control regions (odds ratio [OR] of the interaction term: 2.32; 95% confidence interval [CI]: 1.01-5.35). With respect to helmet use, a non-statistically significant upward trend was observed in the Sherbrooke area (going from 43.5% to 60.6%). This figure remained stable in the control regions (going from 41.5% to 41.9%). No significant difference was observed in the evolution of helmet use between the two groups (OR of the interaction term of 2.70; 95% CI: 0.67-10.83).

CONCLUSION

After the bylaw was adopted, bicycle use among youth aged 12 to 17 years in the Sherbrooke area remained stable and helmet used increased, though not significantly.

Unsafe riding behaviors of shared-bicycle riders in urban China: A retrospective survey

Shared-bicycle use has skyrocketed in urban China, but little is known about the safety of bicycle users. The Chinese popular media reports multiple risky riding behaviors among shared bicycle riders, but scientific research on the topic is lacking. Therefore, we conducted a retrospective WeChat-based online survey to examine how often shared bicycle riders report engaging in risky cycling behaviors in urban China. Eight unsafe shared bicycle riding behaviors were assessed: not wearing helmets, running red lights, cycling against the traffic flow, riding in lanes designed for motor vehicles, riding in lanes designed for pedestrians, carrying passengers on bicycles, using cell phones while riding, and eating while riding. In total, 1960 valid questionnaires were collected. The proportion of participants who reported always or often having unsafe riding behavior in the past month, ranged from 1.1% for carrying passengers on the bicycles to 97.6% for failing to wear a helmet. Demographic characteristics were associated with unsafe behaviors through multivariate logistic regression, with male riders and riders aged 25 years or younger more likely to ride while using cell phones than females (AOR = 2.94) and those 36 years or older (AOR = 3.57). Cyclists with undergraduate education were more likely to wear helmets than those with postgraduate education or higher (AOR = 0.21). Compared to riders from central municipalities governed directly by the central government, riders from provincial capitals, deputy provincial cities, and smaller cities were at higher risks of riding in lanes for pedestrians, respectively (AOR = 1.59, 2.82 and 1.61). Riders who rode over 5 h a week and who rode on weekends were more likely to carry passengers than those who rode less than 1 h a week (AOR = 4.72) and those who rode only on weekdays (AOR = 3.93). We conclude that shared-bicycle riders frequently engage in some unsafe riding behaviors in urban China. Younger age, lower level of education, and longer hours of riding each week are associated with greater risks of some unsafe riding behaviors. Shared bicycles offer substantial benefit to societal health and transportation, but evidence-based interventions should be considered to reduce risks from unsafe shared bicycle riding behaviors. A well-designed road infrastructure with dedicated on-road bicycle lanes and readily-accessible comfortable, low-cost, and safe helmets may also reduce unsafe riding behaviors and unwanted crashes and injuries for shared bicycle riders.

Well-being, behavioral patterns and cycling crashes of different age groups in Latin America: Are aging adults the safest cyclists?

Objectives

This study aimed at analyzing the cycling safety-related factors and the mental health indicators of elderly cyclists in comparison with other age groups.

Methods

For this cross-sectional study, we analyzed the data of 911 bicyclists from two Latin American countries that have been experiencing a substantial growth of urban cycling during the last few years: Colombia and Argentina. Participants responded to an e-questionnaire on bicycling behaviors, mental health and cycling safety.

Results

Aging adults reported lower rates of risky behaviors and traffic crashes (around .38 in five years), and, on the other hand, more cycling protective behaviors, a higher risk perception and a better knowledge of traffic norms than both other adults (26–50 years old) and young cyclists (<26). Cycling behaviors and crashes were found to be significantly related to mental health indicators, the latter being higher in aging cyclists. However, this population remains more prone to distractions experienced while cycling than other age groups.

Conclusions

Although the behavioral features of aging adults were comparatively “safer” than the ones displayed by other age groups, factors such as cycling distractions and this population’s over-representation in traffic crashes suggest the need of enforcing policymaking for a better integration of this age segment in alternative transportation dynamics.

The impact of bicycle helmet legislation on cycling fatalities in Australia

Background

Australian bicycle helmet laws were first introduced in Victoria in July 1990 and the remaining Australian states, Australian Capital Territory and Northern Territory by July 1992. Previous research on helmet legislation has focused on changes in helmet wearing and bicycle-related head injury. Although it is generally accepted that bicycle helmets can reduce the risk of fatality due to head injury, there has been little research assessing the impact of helmet legislation on cycling fatalities.

Methods

An interrupted time series approach was used to assess the impact of bicycle helmet legislation on yearly-aggregated rates of bicycle-related fatalities per population from 1971 to 2016.

Results

Immediately following bicycle helmet legislation, the rate of bicycle fatalities per 1 000 000 population reduced by 46% relative to the pre-legislation trend [95% confidence interval (CI): 31, 58]. For the period 1990–2016, we estimate 1332 fewer cycling fatalities (95% CI: 1201, 1463) or an average of 49.4 per year (95% CI: 44.5, 54.2). Reductions were also observed for pedestrian fatalities; however, bicycle fatalities declined by 36% relative to pedestrian fatalities (95% CI: 12, 54).

Conclusions

In the absence of robust evidence showing a decline in cycling exposure following helmet legislation or other confounding factors, the reduction in Australian bicycle-related fatality appears to be primarily due to increased helmet use and not other factors.

Helmet use and bicycle-related trauma injury outcomes

Background: It is essential to identify factors that predict helmet use, so as to mitigate the injury and mortality from bicycle accidents.Objective: To examine the relationship between helmet use and the bicycle-related trauma injury outcomes among bicyclists with head/neck injury in the US.Methods: Data from the 2002-2012 National Trauma Data Bank were used, including all trauma bicycle riders involved in bicycle-related accidents whose primary reason for the hospital or Intensive Care Unit stay was head or neck injury. Using multiple logistic regression, the association between helmet use, Injury severity score (ISS), length of stay in hospital (HLOS) and Intensive Care Unit (ICULOS), and mortality was examined.Results: Of the 76,032 bicyclists with head/neck injury, 22% worn helmets. The lowest was among Blacks, Hispanics, and <17 years old. Wearing a helmet significantly reduces injury severity, HLOS, ICULOS, and mortality (i.e total and in-hospital). Males had a severe injury, longer HLOS, ICULOS, and higher mortality than female. Blacks and Hispanics had longer HLOS and ICULOS and higher total mortality than Whites, but had a similar chance for in-hospital mortality.Conclusions: More effort is needed to enhance helmet use among at-risk bicycle riders, which may reduce injury severity, HLOS, ICULOS, and mortality.

Recommend or mandate? A systematic review and meta-analysis of the effects of mandatory bicycle helmet legislation

If all cyclistswere wearing helmets, significant numbers of head injuries might theoretically be prevented. Mandatory bicycle helmet legislation increases helmet use but is a controversial measure. Results from 21 studies of the effects of mandatory bicycle helmet legislation on injuries among crash involved cyclists were investigated by means of meta-analysis and the effects of several potential biases were investigated. The summary effect of mandatory bicycle helmet legislation for all cyclists on head injuries is a statistically significant reduction by 20% (95% confidence interval [-27; -13]). Larger effects were found for serious head injury (-55%; 95% confidence interval; [-78; -8]). Among children, larger effects were found when legislation applies to all cyclists than when it applies to children only. There is no clear indication of the results being affected by publication bias. Publication bias may exist, but any existing biases seem to more or less outweigh each other. Results from meta-analysis do not indicate that the results are systematically affected by a lack of control for time trend bias, choice of comparison group or study design (before-after vs. case control). Summary effects may be somewhat overestimated because of a lack of control for potential confounding variables in some of the studies. However, such a bias, if it exists, is not likely to be large. Empirical evidence for the hypotheses that mandatory bicycle helmet legislation deters people from cycling and that helmet wearing leads to behavioral adaptation is mixed. In summary, mandatory bicycle helmet legislation can be expected to reduce head injury among crash involved cyclists. Some adverse effects may occur, but will not necessarily be large or long-lasting. People who may be deterred from cycling, are among those with the highest injury risk and the smallest health effects from cycling. If the overall goal is to improve safety for all cyclists and to increase cycling, mandatory bicycle helmet legislation should be supplemented by other measures, especially improved bicycle infrastructure.

Bicycle-related injuries among children treated in US emergency departments, 2006-2015

OBJECTIVE

One of the leading causes of non-fatal injury among children is bicycling. Past studies indicate that helmets are protective against bicycle-related injuries and involvement of motor vehicles is associated with severe injuries, but research utilizing a nationally representative data set for this population and focusing on these risk factors does not exist. The objective of this study was to describe the epidemiology of bicycle-related injuries among children treated in hospital emergency departments (EDs) in the United States (US).

METHODS

A retrospective analysis was conducted with data from the National Electronic Injury Surveillance System for children 5-17 years of age who were treated in US EDs from 2006 through 2015 for a bicycle-related injury. Helmet use and motor vehicle involvement were two variables that were created and coded using keyword searches of the case narratives. Rates of injuries over time were described. Multivariate logistic regression along with 95% confidence intervals (CIs) were used to contrast types of injuries sustained among injured helmet users with non-users.

RESULTS

An estimated 2 219 742 (95% CI: 1 871 120-2 568 363) children 5-17 years of age were treated in US EDs for bicycle-related injuries over the 10-year study period, an average of 608 injuries per day. Most injuries (45.7%) involved children 10-14 years of age. The rate of bicycle-related injuries significantly decreased from 447.4 per 100 000 children in 2006 to 321.1 per 100 000 children in 2015 (P < 0.001). Helmet use at the time of injury was significantly associated with lower likelihood of head and neck injuries (OR: 0.52 [95% CI: 0.40-0.59]) and hospitalizations (OR: 0.71 [95% CI: 0.54-0.94]), but there was no significant change in the rate of injury among helmet users over the study period (P = 0.224). Motor vehicle involvement increased the odds of bicycle-related traumatic brain injuries (TBIs) (OR: 1.98 [95% CI: 1.49-2.64]) as well as injury-related hospitalizations (OR: 4.04 [95% CI: 3.33-4.89]).

CONCLUSIONS

Despite decreasing injury rates, bicycling remains an important source of injury for children. Helmet use has demonstrated significant protective effects for TBIs, head and neck injuries, and hospitalizations. Motor vehicle involvement increased the risk of hospitalization. More efforts are needed to promote use of helmets and to reduce the possibility of bicycle-motor vehicle collisions to prevent bicycle-related injuries among children.

Helmet use in preventing acute concussive symptoms in recreational vehicle related head trauma

OBJECTIVES

Helmets use has proved effective in reducing head trauma (HT) severity in children riding non-motorised recreational vehicles. Scant data are available on their role in reducing concussive symptoms in children with HT while riding non-motorised recreational vehicles such as bicycles, push scooters and skateboards (BSS). We aimed to investigate whether helmet use is associated with a reduction in acute concussive symptoms in children with BSS-related-HT.

METHODS

Prospective study of children <18 years who presented with a BSS related-HT between April 2011 and January 2014 at a tertiary Paediatric Emergency Department (ED).

RESULTS

We included 190 patients. Median age 9.4 years (IQR 4.8-13.8). 66% were riding a bicycle, 23% a push scooter, and 11% a skateboard. 62% were wearing a helmet and 62% had at least one concussive symptom. Multivariate logistic regression analysis adjusting for age, gender, and type of vehicle showed that patients without a helmet presented more likely with headache (adjusted odds-ratio (aOR) 2.54, 95% CI 1.27-5.06), vomiting (aOR 2.16, 95% CI 1.00-4.66), abnormal behaviour (aOR 2.34, 95% CI 1.08-5.06), or the presence of at least one concussive symptom (aOR 2.39, 95% CI 1.20-4.80).

CONCLUSIONS

In children presenting to the ED following a wheeled BSS-related HT helmet use was associated with less acute concussive symptoms.

ABBREVIATIONS

aOR, adjusted odds ratio; APHIRST, Australasian Paediatric Head Injury Rules Study; BSS, bicycles, push scooters and skateboards; CI, confidence interval; CT, computed tomography; ED, emergency department; HT, head trauma; IQR, interquartile range; OR, odds ratio; RCH, Royal Children's Hospital; RV, recreational vehicle.

Bicycle Helmets save More than Heads: Experience from a Pediatric Level I Trauma Hospital

We studied pediatric bicycle accident victims (age ≤ 15 years) who were treated at our pediatric Level I trauma center during a 10-year period. Demographic data, injury severity, hospital course, and hospital cost data were collected. We compared the children who were helmeted to those who were unhelmeted. Our study cohort consisted of 516 patients. Patients were mostly male (70.2%) and white (84.7%); the median age was nine years. There were 101 children in the helmet group and 415 children in the unhelmeted group. Helmeted children were more likely to have private insurance (68.3% vs 35.9%, P < 0.001). Unhelmeted children were more likely to sustain multiple injuries (40% vs 25.7%, P = 0.008), meet our trauma activation criteria (45.5% vs 16.8%, P < 0.001), and be admitted to the hospital (42.4% vs 14.9%, P < 0.001). Helmeted children were less likely to sustain brain injuries (15.8% vs 25.8%, P = 0.037), skull fractures (1% vs 10.8%, P = 0.001), and facial fractures (1% vs 6%, P = 0.040). Median hospital costs were more expensive in the unhelmeted group. Helmet usage was suboptimal. Although most children sustained relatively minor injuries, the unhelmeted children had more injuries and higher costs than those who used helmets. Injury prevention programs are warranted.

Road traffic injuries among children and adolescents in Singapore - Who is at greatest risk?

INTRODUCTION

Pediatric road traffic injuries remain a significant cause of death and disability in many countries in Asia, despite the implementation of road traffic safety laws. We aim to describe the injuries, the use of restraints among road users, and risk factors associated with severe injuries for children in Singapore.

METHODS

We performed a retrospective chart review of road traffic injuries presenting to the only two pediatric tertiary care hospitals in Singapore, from January 2012 to April 2016. We included children <16years old presenting to the emergency departments within 24h after injury (pedestrian, bicycle, motorcycle, motor vehicle). We calculated the frequencies for specific injury mechanisms, injury severity scores (ISS), and in-hospital outcomes of severe injuries (death, urgent resuscitation and emergent surgery). We performed a multivariate logistic regression to determine risk factors associated with severe injury.

RESULTS

There were 2468 patients during the study period. The mean age was 7.9 years (SD 4.7); 60.1% of road injuries involved motor vehicle occupants (1483/2468). Most bicyclist/motorcyclists were not wearing helmets (70.0%, 245/350) and 51.1% of motor vehicle passengers (758/1483) were not restrained. Compared to motor vehicle passengers, pedestrians (adjusted OR 2.38, 95% CI 1.41-3.99), bicyclists (adjusted OR 2.12, 95% CI 1.04-4.32) and motorcyclists (adjusted OR 6.09, 95% CI 2.04-18.24) were more likely to sustain severe injuries.

CONCLUSION

Child pedestrians, bicyclists and motorcyclists are especially vulnerable for severe injures. Further injury prevention efforts must focus on the enforcement of legislation to protect these high-risk groups.

Bicycle helmets are highly protective against traumatic brain injury within a dense urban setting

BACKGROUND

New York City (NYC) has made significant roadway infrastructure improvements, initiated a bicycle share program, and enacted Vision Zero, an action plan to reduce traffic deaths and serious injuries. The objective of this study was to examine whether bicycle helmets offer a protective advantage against traumatic brain injury (TBI) within a contemporary dense urban setting with a commitment to road safety.

METHODS

A prospective observational study of injured bicyclists presenting to a Level I trauma centre was performed. All bicyclists arriving within 24 h of injury were included. Data were collected between February, 2012 and August, 2014 and included demographics, imaging studies (e.g. computed tomography (CT)), injury patterns, and outcomes including Glasgow Coma Scale (GCS) and Injury Severity Score.

RESULTS

Of 699 patients, 273 (39.1%) were wearing helmets at the time of injury. Helmeted bicyclists were more likely to have a GCS of 15 (96.3% [95% Confidence Interval (CI), 93.3-98.2] vs. 87.6 [95% CI, 84.1-90.6]) at presentation. Helmeted bicyclists underwent fewer head CTs (40.3% [95% CI, 34.4-46.4] vs. 52.8% [95% CI, 48.0-57.6]) and were less likely to sustain intracranial injury (6.3% [95% CI, 2.6-12.5] vs. 19.7% [14.7-25.6]), including skull fracture (0.9% [95% CI, 0.0-4.9] vs. 15.3% [95% CI, 10.8-20.7]) and subdural hematoma (0.0% [95% CI, 0.0-3.2] vs. 8.1% [95% CI, 4.9-12.5]). Helmeted bicyclists were significantly less likely to sustain significant TBI, i.e. Head AIS ≥3 (2.6% [95% CI: 0.7-4.5] vs.10.6% [7.6-12.5]). Four patients underwent craniotomy while three died; all were un-helmeted. A multivariable logistic regression model showed that helmeted bicyclists were 72% less likely to sustain TBI compared with un-helmeted bicyclists (Adjusted Odds Ratio 0.28, 95% CI 0.12-0.61).

CONCLUSIONS

Despite substantial road safety measures in NYC, the protective impact of simple bicycle helmets in the event of a crash remains significant. A re-assessment of helmet laws for urban bicyclists is advisable to most effectively translate Vision Zero from a political action plan to public safety reality.