In addition to organized sports, today’s youth are commonly involved with higher risk activities via the use of trampolines and in-line skates and participation in other activities that have resulted in an increase in the number of traumatic injuries.¹ Oftentimes, these serious injuries occur without any adult supervision, leading to a delay in the treatment of medical emergencies.

Providing on-site professional medical care at all youth sporting events regardless of the level of competition is not solely an issue of cost, but also one of human resources. The absence of qualified medical personnel on-site at youth sporting events should not mislead the public into realizing that the risk and severity of injuries sustained by children is of less importance than to those sustained by adults. In fact, in many cases, the risk, prevalence, and severity are of greater concern given the immaturity of a child’s anatomical features and underdevelopment of certain vital organs. Given the predicted continual growth identified with youth sport involvement, parents and others will need to adapt improved guidelines for emergency care of traumatic-type injuries to children. Medical emergencies are not the same with children as with adults for a variety of reasons.

With the recent popularity of bicycle sports, in particular those referred to as “extreme sports” that attract risk-taking challenges, thoracic wall injuries are commonplace among pediatric and adolescent children. Investigators have identified thoracic trauma as the second leading cause of death in children, behind brain injuries.⁷ Although these types of injuries are not seen as often in children as they are in adults, they remain a source of morbidity and mortality.⁹ The compliant chest wall of children affords far more opportunistic injuries, such as pulmonary contusions and rib fractures.⁶ Additionally, children’s thoracic-wall anatomy and physiology differs from that of an adult with respect to pulmonary function, residual capacity, blood volume, chest wall and spinal soft-tissue mobility, and cardiac function.⁹ Investigators have shown that in the adolescent male, both lung and thoracic development occurs throughout puberty. Conversely, in adolescent females, lung development is almost finished following menarche.¹⁰

Traumatic abdominal wall herniations (TAWH) have been described in the literature more commonly as of late, with an emphasis on the etiology coming from a bicycle accident and the subsequent force of the abdominal wall into the handlebars.^11-12 Perhaps not surprisingly, children as young as 7 have suffered intra-abdominal injuries, requiring surgical intervention in many cases.^13-14 The use of additionally padded handlebars may or may not prevent injury. Similar types of injuries have also been reported in children under 17 taking part in alpine-skiing activities, in particular with trauma to the kidneys.¹⁵ Additionally, one report described a case of a congenital solitary kidney (renal agenesis) in a 17-year-old offensive lineman who landed on his buttocks while participating in football. The youth presented with typical findings, such as pain in the lower back and gluteal region, radiating pain down the leg, and shortness of breath. A CT scan that showed a hematoma without renal abnormality, and the absence of a right kidney. Renal agenesis is very rare, and no evidence exists regarding the risk of return to a sport, particularly one such as football.¹⁶

It is not uncommon for a child to actually sustain a fracture, complain of pain, and have it written off by a parent or coach as anything from a simple “bruise” to a “growing pain.” The same child only hours later may even be playing actively in the backyard, only to come to find out days later that a fracture does in fact exist in a bone. Furthermore, referral patterns from injuries to internal organs may not be identified or accurately reported by a child. Yet another area of recent concern is symptoms reported by a child following a concussion, and how accurate the subjective history may be. A head injury sustained by a child may in fact be more severe than that suffered by an adult due to the ongoing neurocognitive development of the child’s brain.^17-18 Researchers found that following a sustained concussion, female athletes tend to have significantly greater declines in both simple and complex reaction times when compared to baseline testing prior to the concussion.¹⁹ Additionally, females reported more symptoms post-concussion than males of similar circumstances. In fact, females were found to be nearly 1.7 times more cognitively impaired versus males following a concussion. This is an important tool for assessment, as the reporting of a greater number of symptoms may not necessarily simply correlate to a more severe injury. The inaccuracy of self-reported symptoms by children complicate the assessment and decision-making process and should always be taken into account before return-to-play clearance. For this reason, baseline assessments are being conducted on this age group. Examples of sports that pose the greatest risk for head injury in children include football, soccer, and diving.

Psychological Impact: Associated with the physical immaturity of identifying children’s injuries, a component of psychological immaturity exists. One could understand the normal thought process of a child who has not yet formulated adult-like decision-making skills, but complementary to this circumstance may include an over-zealous parent who may influence a child’s thought process. At increasingly alarming rates, parents place added pressures on their children not only to participate, but to succeed at high levels in sports. This has contributed to an abundance of physical and emotional outcomes, such as overuse injuries from the physiological perspective, as well as feelings of burnout, disinterest, and even withdrawal from a child who is being pushed to play without an adequate level of self-enjoyment. Children who play sports against their own desire and interest tend to display a greater risk of not paying attention to detail, which may ultimately place them in a potentially dangerous situation resulting in a severe injury.

Field Safety

Unfortunately, many injuries to children playing sports are preventable and are the result of poor playing field conditions. Traumatic injuries can also be the result of careless efforts to maintain a safe playing environment. In general, field safety is an area of prevention that can be practiced by all parties involved with youth sports, including parents, coaches, and community recreational employees. A systematic approach should be taken and documented on a regular basis to assess the safety status of all playing surfaces and equipment. Some of the items to be considered as possibly leading to a higher incidence of injury risk might include:¹

All equipment should be carefully inspected and repaired as needed according to any standards or guidelines that may exist. This may include baseball bats, gloves, pads, braces, helmets, and masks, which are typically used and reissued on an annual basis as part of a recreational or organized program. Any equipment issued or reissued should also be properly fit and sized, specifically helmets for sports such as football and ice hockey, and shoulder pads for football, ice hockey, and lacrosse.²¹ Loose-fitting helmets and shoulder pads can lead to a greater impact of forces sustained through direct contact, potentially leading to more serious injuries. Parents, coaches, and healthcare professionals cannot rely on feedback regarding poor-fitting braces, pads, or helmets when asking younger children for their thoughts, as their opinions may not be accurate. Proper fitting of youth sports equipment should not be taken casually, and steps should be taken to learn the appropriate methods.

Some sports and pre-existing injury conditions require unique pieces of equipment that parents, coaches, and healthcare professionals may not be familiar with. An example of this is protective eyewear. The American Academy of Pediatrics in 2004 issued advice pertaining to protective eyewear for young athletes. A summary of the recommendations include:³

Emergency Response

Professional medical care is rare at organized youth sporting activities unless special events are occurring, such as state or national tournaments like Little League World Series. In such absence of on-site care, emergency medical care is managed impromptu, without any advanced planning, and by a coach or parent who is most comfortable aiding and assisting an injured individual, although this person may not be medically credentialed or qualified in any such manner to provide formal care. While the Good Samaritan approach is appreciated, it does not reflect the optimal standard of care. More importantly, it could potentially lead to more harmful and/or mishandled circumstances.^25-26

Emergency actions plans (EAP) should be developed, reviewed, and revised by individuals familiar with the venues of play. This includes administrators, medical personnel, coaches, parents, legal counsel, and others who have a keen awareness of detail. While no particular length of a document exists, attention to detail and planning for safe handling are the critical components to consider. Individual emergency action plans at minimal comprise information included in Table 2.

The EAP should be rehearsed on a scheduled basis, and at minimum be reviewed when new personnel, coaching staff, or others are involved with leadership roles. Components of the plan should also involve a minimal skill set expectation, with coaches and league officials being certified in CPR and the use of automated external defibrillators. It is also a good idea to disseminate written copies of the plan to individuals who will potentially be involved with emergency situations. The plan should be posted in a location where all spectators can see it in the case of an emergency.