Should sledders wear helmets?

Snowy winter days bring delight to many children and teens. Besides school cancellations, snowy days mean snow angels, snow ball fights, and the easiest and most fun activity of all – sledding.  Images of people sledding down the Philadelphia Art Museum steps captured by most TV news stations during the area's snowstorm in late January, say it all.

However, it is clear that sledding, a very popular and seemingly innocuous winter activity, leads to significant injuries. From 1997-2007, an average of 20,820 cases of children each year less than or equal to 19 years of age were treated for sledding-related injuries in U.S. emergency departments, found a 2010 study. That's a yearly rate of 26 cases per 100,000 U.S. residents aged 19 years or less. The head was the most commonly injured (34 percent) body part and children 4 years or younger were four times more likely to sustain an injury to the head than to any body part.  An estimated 4 percent of all cases required hospitalization, most commonly from traumatic brain injuries and fractures

Whether helmet use prevents head injuries from sledding is not as clear.  Injury patterns between unhelmeted sledding and bicycling were compared and found to be similar, as reported in a study.  Over a five year period, researchers found that head trauma occurred at a similar frequency in both groups, representing the most frequent single injury. Skull fractures were more common among sledders, whereas concussions and brain bleeding occurred with equal frequency between groups. Previous investigations have shown that among bicyclists, wearing a helmet decreased the risk of head injury by as much as 85 percent, and the risk of brain injury by as much as 88 percent.  The authors therefore inferred that because of the similarities in bike trauma and sled trauma, helmet use would reduce the morbidity associated with sledding.

Among skiers and snowboarders, the use of helmets clearly decreases the risk of head injuries compared to non-helmeted participants, according to a review of studies in the Journal of Trauma and Acute Care Surgery in 2012.  The investigators also found that the beneficial effects of helmet use are not negated by unintended risks. Their use does not appear to increase the risk of neck injury, or the risk of encouraging recklessness. The high profile deaths of Michael Kennedy and Sonny Bono in skiing accidents in 1998, and the death of Natasha Richardson while going down unhelmeted on a slightly inclined beginner slope in 2009, have helped tip the scale towards helmet use among skiers and snow-boarders.

Is skiing or snowboarding much riskier than sledding? Skiers and snowboarders definitely slide down the mountain at higher velocities. However, there are many more sledders than skiers or snow-boarders. Sleds are easily accessible, and unsteerable vehicles used largely on ungroomed slopes sometimes with fixed obstacles, and are not patrolled. A single institution reported that sledding accounted for 50 percent of all their winter sport admissions from 1991-1997,  found a study from 1999.

Even the experts equivocate. This year's winter safety tips from the American Academy of Pediatrics state "Consider having your child wear a helmet while sledding". The American Academy of Orthopedic Surgeons state that young children should wear a fitted helmet while sledding as a preferred versus essential precaution.

In the meantime, sledding injuries, some devastating, continue to occur yearly.  In recent years, some US cities, fueled by the prospect of costly lawsuits, banned or at least restricted sledding on public property. Last year, the city of Dubuque in Iowa banned sledding in all but two of its 49 parks. In 2009, the then Massachusetts state senator sponsored a mandatory helmet bill for sledding children under a certain age. The bill stalled in legislature.

Detractors of helmet use for sledding think that the practice goes with "the bubble-wrap your child mentality" of societal and parental over-protectiveness of children that might stifle children's happiness and growth. Some worry that if children were required to wear a helmet for sledding, they might not sled as much. Even proponents for requiring helmet use do not know how to enforce it.

As a pediatric emergency physician, my world view on safety may be skewed. And I will always advocate for any strategy that has been shown to prevent injury. Needing to wear a seatbelt never squelched my daughter's desire to learn to drive. My teen-age kids grab their bike helmets before they take their bikes from the rack, and they will never snowboard without a helmet. I should have put helmets on them when I started taking them sledding as toddlers. Now, they look at me with disdain when I run after them with helmets as they sled with their friends.

If possible, wear a helmet designed for winter sports. If you don't have a ski or winter sports helmet, at least wear the helmet you use for biking or skateboarding, according to a tip sheet from TeensHealth about sledding.

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