Pediatric Helmet Use in Residential Areas

Bicycle and other nonmotorized vehicles remain a leadingcauseofseriousheadinjuryinchildrenwith most of these injuries being entirely preventable.1 In 2005, 44 per cent of nonfatal bicycle injuries occurred in children and youth aged 5 to 20 years, whereas children aged 0 to 20 years made up approximately 23 per cent of bicycle fatalities.2 In 2000, head in- juries accounted for 62.6 per cent of bicycle fatalities among children and youth aged 0 to 19 years.2 The use of a helmet has clearly reduced the severity of injuries sustained by pediatric bicyclists,3 yet despite the com- pelling benefits of helmet safety, bicycle helmet use is still low and the reasons are vast and multidimensional.

Despite bicycle crashes being a leading cause of un- intentional death in the 5- to 14-year-old age group, there still remain societal misconceptions with regard to helmet use by children around the residential home as compared with major intersections and urban settings. Nearly 60 per cent of all childhood bicycle-related deaths occur on minor roads. The typical bicycle/motor vehicle crash occurs within one mile of the bicyclist's home. After over a decade of successful bicycle injury prevention programs across North America, there re- main large gaps in public awareness and preventive programming, particularly in isolated and rural com- munities. Because the protective effect of bicycle hel- mets is well documented in the literature, the objective of this study was to determine the association between helmet use and head injury in domestic environments as typified by the home. The study will also serve to eval- uate the association of ethnicity and gender with helmet use in residential settings.

This was a retrospective review using the National Trauma Data Bank (NTDB) of the Committee on Trauma of the American College of Surgeons for the years 2007 to 2008. It is the largest aggregation of U.S. trauma registry data ever assembled. The 2007 to 2008 data sets contain records of approximately 1.13 million trauma patients from 592 trauma centers in 43 states, territories, and the District of Columbia. Patients from the years 2007 and 2008 were chosen as a result of the NTDB's adoption in 2007 of the National Trauma Data Standard, which significantly improved the qua- lity of the data set. Included were all pedal cyclists as identified by the International Classification of Dis- eases, 9th Revision code (E826.6) with no motorized involvement younger than 18 years whose injury loca- tion was identified as home and had information on helmet use.

Demographic data on age, gender, and insurance status were assessed. Data on injury severity were also collected, including Injury Severity Score, presence of hypotension on arrival to the emergency department (systolic blood pressure less than 90 mmHg) (14), se- vere head and/or extremity injury (Abbreviated Injury Scale score 3 or greater), type of injury (penetrating vs blunt), and mechanism of injury (11). A bivariate analysis comparing patients with and without a hel- met was undertaken using Pearson's x2 test for cate- gorical variables and the Wilcoxon rank-sum test for continuous variables. The main outcome of interest was the presence of severe head injury as defined by the head Abbreviated Injury Score of 3 or greater. Multi- variate analysis was then performed to determine the independent predictors of severe head injury after crashes involving a pediatric cyclist in a domestic en- vironment. The model adjusted for patient-level char- acteristics including age, gender, race, insurance, Injury Severity Score, hypotension on arrival to the emergency department, presence of extremity trauma, and type and mechanism of injury. In addition we also adjusted for helmet use, intentional versus unintentional injuries, and year of admission. A secondary analysis was conducted to determine the potential demographic predictors of helmet use. Statistical analyses were performed using Stata MP Statistical Software: Release 11 (StataCorp, College Station, TX). Statistical significance was set at P <.05.

There were a total of 885 cyclists who met the in- clusion criteria. The median age was 9 years with an interquartile range of 6 to 12 years. The majority was male (69%) and of white race/ethnicity (65.0%) fol- lowed by Hispanics (10.2%) and blacks (7.5%). Just over one-fourth of the patients were documented as using a helmet (27.2%). Eighty-eight per cent of pa- tients had an Injury Severity Score of less than 15. On bivariate analysis, helmet use was significantly higher among whites and Asians (30.6 and 33.3%) compared with blacks and Hispanics (16.7 and 10.0%, P < 0.001). Helmet use among females was higher when compared with males (32.9 vs 24.7%, P 4 0.01). The proportion of severe head injuries among nonhelmet users was higher than those with helmets (15.1 vs 2.1%, P < 0.001). Patients with a helmet tended to have a higher proportion of extremity injuries when com- pared with nonhelmet users (5.8 vs 2.2%, P 4 0.01). There was no difference in the use of helmets by in- surance status. On multivariate analysis, helmet use was associated with a 90 per cent reduction in odds of severe head injury as compared with nonusers (odds ratio [OR], 0.10; confidence interval [CI], 0.03 to 0.27; P < 0.001). Female gender was a positive pre- dictor of helmet use (OR, 1.44; CI, 1.00 to 2.08; P 4 0.048; Table 1), whereas Hispanic ethnicity was as- sociated with lower odds of helmet use compared with whites (OR, 0.24; CI, 0.11 to 0.52; P <0.001; Table 2).

The present study is the first to highlight the impact of helmet use on pediatric cyclist injuries within a resi- dential setting. The study demonstrated that helmet use protects against severe head injury, even in residential road traffic injuries. Although the association between higher helmet use and lower head injuries has been well documented and validated in the literature, this study provides insight into helmet use in a population most at risk for bicycle head injuries in a setting where research is lacking. In an ecological study of a large NorthAmericancity,Wessonetal.4 also showed that as bike helmet use rate rose from four per cent in 1990 to 67 per cent in 1996, the number of head injury admissions fell from 46 to 24 per cent. However, the study design did not permit direct assessment of the impact of helmet use on rates of head injury. In contrast, our data, derived from a national database, demonstrate a direct association between individual helmet use and admission for severe head injury. Our study con- firms earlier findings by Coffman et al.1 that children who wear helmets experience fewer head injuries and decreased severity of injury.

In this study, we found ethnic differences in the use of helmets around residential homes. Although nu- merous studies have identified the factors associated with cycle helmet ownership and use, few have inves- tigated the relationship between ethnicity and helmet use around the home. Our study showed that Hispanic children are less likely to use helmets compared with whites. Lower rates of helmet use among Hispanic and black children may reflect differences in parental edu- cational attainment, socioeconomic status, and risk- seeking child behavior.

As expected, helmet use significantly reduced the odds of severe head injury, as has been previously reported.3 Females demonstrated significantly higher helmet use and experienced fewer severe head injuries when compared with males. Analogous findings in previous studies have been attributed to different pa- rental attitudes toward protective equipment for girls rather than boys and higher helmet refusal in boys compared with girls. In addition, there may be physio- logical and psychological explanations for differential risk attitudes among genders and an understanding of these differences may help to establish improved life- long helmet practices for boys.

Limitations of this study include small sample size, lack of data on pre-existing comorbid factors and so- cioeconomic status, the retrospective nature of the data set, and the inability to measure the long-term outcomes of patients with head injuries regarding psychomotor function and independent functional status. Despite these limitations, this study is one of the few to ex- amine the predictors and impact of helmet use around residential dwellings and represents the largest sample size available in this subset.

This study highlights the importance of helmet use for reducing head injuries among pediatric cyclists even in residential areas. Helmet use and education should be encouraged for those children riding bicycles in or around their neighborhoods. In addition, the long- term outcomes of mild injuries on developmental abil- ities of children and the impact of head injuries on family and social relationships along with educational development require further research.

REFERENCES

1. Coffman S. Bicycle injuries and safety helmets in children. Review of research. Orthop Nurs 2003;22:9-15.

2. Anonymous. Children's Safety Network. Available at: www. childrenssafetynetwork.org/. Accessed June 13, 2011.

3. Abu-Kishk I, Vaiman M, Rosenfeld-Yehoshua N, et al. Riding a bicycle: do we need more than a helmet? Pediatr Int 2010;52:644-7.

4. Wesson D. Trends in bicycling-related head injuries in chil- dren after implementation of a community-based bike helmet campaign. J Pediatr Surg 2000;35:688-9.

Presented as an oral presentation at the Annual Academic Surgical Congress, Las Vegas, NV, February 14, 2012.

Address correspondence and reprint requests to Tolulope A. Oyetunji, M.D., M.P.H., Department of Surgery, Howard University College of Medicine, 2041 Georgia Avenue NW, Washington, DC 20060. E-mail: [email protected].

Tolulope A. Oyetunji, M.D., M.P.H.

Department of Surgery,

Howard University College of Medicine,

Washington, DC

Michael A. Fisher, B.S.

Howard University College of Medicine,

Washington, DC

Sharon K. Onguti, M.D., M.P.H.

Howard-Hopkins Surgical Outcomes Research Center,

Department of Surgery,

Howard University College of Medicine,

Washington, DC

Edward E. Cornwell, M.D.

Department of Surgery,

Howard University College of Medicine,

Washington, DC

Faisal G. Qureshi, M.D.

Department of Surgery,

Children's National Medical Center,

Washington, DC

Fizan Abdullah, M.D., Ph.D.

Division of Pediatric Surgery,

Johns Hopkins University School of Medicine,

Baltimore, Maryland

Adil H. Haider, M.D., M.P.H.

Department of Surgery,

Johns Hopkins University School of Medicine,

Baltimore, Maryland

Benedict C. Nwomeh, M.D., M.P.H.

Department of Surgery,

Nationwide Children's Hospital,

Columbus, Ohio