Head injuries occurring during recreational activities such as bicycling and in-line skating are common. The use of helmets substantially reduces the incidence of head injury; however, poor helmet fit has been shown to increase the rate of head injury. Although the American Academy of Pediatrics recommends helmet use, there are no recommendations for assessing proper helmet fit during routine anticipatory guidance at well-child visits. Parkinson and Hike conducted this study to document the prevalence of proper helmet condition and fit in a primary care setting.

Families with children and adolescents four to 18 years of age were contacted by telephone one to two days before their well-child visit and instructed to bring in the child’s or adolescent’s helmet. A 15-item questionnaire that assessed demographics, helmet-use patterns, helmet condition, teaching of helmet fit, and related items was administered. The parent or patient was then instructed to fit the helmet as well as possible. Helmet and fit were assessed according to a 14-component protocol that judged stability, condition, head room, and strap. To be considered a “pass,” all 14 components had to be passed.

Only 4 percent of children and parents (20 of 479) passed the entire evaluation of condition and fit. Major problems included the following: (1) helmet resting position too high on the forehead; (2) improper strap position (failure of strap to make a ‘V’ around the ears); and (3) excessive front-to-back movement of the helmet. Helmet pass rates were 66 percent for head room, 55 percent for condition, 21 percent for strap, and 20 percent for stability.

The authors conclude that, even in this controlled setting, the overwhelming majority of children, adolescents, and their parents cannot properly fit a bicycle helmet. The three major problem components result in exposure of the head’s frontal region, which is the most common site of impact in bicycle head injuries. Improper helmet use has been estimated to increase the risk of head injury by a factor of three. This study suggests that, although the reported use of helmets was high, most children and adolescents are receiving suboptimal head protection. Based on these results, the authors speculate that better helmet fit could help reduce the rate of head injuries. They recommend that assessment of helmet fit become a part of well-child visits.