Organizational Principles to Guide and Define the Child Health Care System and/or Improve the Health of all Children

POLICY STATEMENT Baseball and Softball

COUNCIL ON SPORTS MEDICINE AND FITNESS abstract KEY WORDS Baseball and softball are among the most popular and safest sports in balls, bats, commotio cordis, elbow, equipment, helmets, injury, which children and adolescents participate. Nevertheless, traumatic and pitch count, safety, shoulder overuse injuries occur regularly, including occasional catastrophic injury ABBREVIATIONS AED—automated external defibrillator andevendeath.Safetyoftheathlete is a constant focus of attention CPSC—Consumer Protection Safety Commission among those responsible for modifying rules. Understanding the stresses NEISS—National Electronic Injury Surveillance System placed on the arm, especially while pitching, led to the institution of rules NOCSAE—National Operating Committee on Standard for Athletic Equipment controlling the quantity of pitches thrown in youth baseball and established UCL—ulnar collateral ligament fi rest periods between pitching assignments. Similarly, eld maintenance This document is copyrighted and is property of the American and awareness of environmental conditions as well as equipment mainte- Academy of Pediatrics and its Board of Directors. All authors nance and creative prevention strategies are critically important in mini- have filed conflict of interest statements with the American fl mizing the risk of injury. This statement serves as a basis for encouraging Academy of Pediatrics. Any con icts have been resolved through a process approved by the Board of Directors. The American safe participation in baseball and softball. This statement has been en- Academy of Pediatrics has neither solicited nor accepted any dorsed by the Canadian Paediatric Society. Pediatrics 2012;129:e842–e856 commercial involvement in the development of the content of this publication. INTRODUCTION All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, The pediatrician needs to have an understanding of baseball and softball. revised, or retired at or before that time. This will allow the pediatrician to offer appropriate counseling and guidance to the many boys and girls, their parents, and members of the sporting community who participate in baseball and softball each year. Baseball is one of the most popular sports in the United States, with an estimated 8.6 million children ages 6 to 17 participating annually in or- ganized and recreational baseball.1 Although baseball is a relatively safe sportincomparisonwithmanyotherathleticactivities,highlypublicized catastrophic impact injuries from contact with a ball or a bat frequently raise safety concerns.2,3 These incidents, as well as the high frequency of shoulder and elbow injuries resulting from overload and overuse, pro- www.pediatrics.org/cgi/doi/10.1542/peds.2011-3593 vide the impetus for this review and new guidance to reduce injury risk doi:10.1542/peds.2011-3593 and improve safety in baseball for 5- to 18-year-old participants. This PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). policy statement replaces the previous statement written in 2001.4 This Copyright © 2012 by the American Academy of Pediatrics statement has been endorsed by the Canadian Paediatric Society. Beginning in the early 1990s, epidemiological and injury surveillance research in baseball and softball intensified. Data from these scientific efforts paved the way for organized baseball to create medical advisory committees, which generated policies designed to reduce the risks of injury in baseball and softball. Advances in equipment also continue to offer new opportunities to make the game safer for youth athletes; similarly, the dissemination and use of automatic lightning detectors (which produce a clear and loud warning signal) and automated external defibrillators (AEDs) provide additional means of reducing catastrophic events on the baseball field.5,6 Moreover, organized youth baseball coaches, officials, and administrators must remain knowledgeable and

e842 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from www.aappublications.org/news by guest on September 25, 2021 FROM THE AMERICAN ACADEMY OF PEDIATRICS sensitive to the developmental and skill Electronic Injury Surveillance Sys- Also in 2007, the NEISS recorded ex- levels of young baseball players and tem (NEISS) through a network of actly 1188 youth softball injuries in the continue to modify the rules, when approximately 100 participating US same 100 participating emergency de- necessary, for the safety of the players. emergency departments. From the data partments. Girls accounted for 1062 This policy statement focuses princi- collected from this cross section of injuries, and boys accounted for 126.17 pally on baseball, but softball will also national emergency departments, the For girls, the frequency of injuries by be considered where relevant literature CPSC extrapolates national estimates age also followed a bell-shaped curve is available. of injury prevalence in various age for ages 5 to 18 years, with the high- groups. The overall prevalence of all est numbers of injuries clustered in PARTICIPATION sports-related injuries in children children from 13 to 16 years of age There are over a dozen youth baseball younger than 15 years seen in an (more than 130 injuries per year of organizations whose combined annual emergency department is just under age). The distribution of injuries by participation is nearly 5 million. Little a million per year; in 2007, the CPSC body region was more evenly distrib- League Baseball reports baseball par- estimated that 109 202 baseball- and uted for girls playing softball com- ticipation at approximately 2.3 million softball-related injuries among 5- to pared with boys playing baseball, with annually and softball participation 14-year-old children were treated in 28% of girls’ softball injuries involving at 400 000 per year7;theBabeRuth US emergency departments nation- the head and neck, 35% involving the League (and its 12-and-under Cal Ripken ally.17 More specifically, in 2007, the upper extremities, 31% involving the Baseball division) has more than 1 CPSC/NEISS recorded exactly 3343 lower extremities, and 5% involving million youth participants annually.8 baseball injuries among 5- to 18-year- the trunk and pubic area. The 5 most Over 2 million girls between the ages old children from the participating US common areas for injury were the of 12 and 18 compete in fast pitch emergency departments (T.J. Schroeder, face (14%), ankle (14%), finger (13%), softball annually. The National Feder- MS, personal communication, 2009). The knee (11%), and head and neck (11%).17 ation of State High School Associations frequency distribution of injuries by age Thirty-nine percent of injuries were 2009–2010 participation data counted followed a bell-shaped curve for ages 5 classified as contusions, abrasions, lac- 473 503 baseball players (ages 14–18) to 18 years, with the highest number of erations, or hematomas/hemorrhages; and 393 578 softball athletes.9 injuriesclusteredinchildrenfrom11to 31% were classified as sprains or 14 years of age (more than 300 injuries strains; 21% were classified as fractures, INJURY DATA per year of age).17 Because 11- to 14- dislocations, or avulsions; 4% were clas- fi There are a variety of sources of data year-old children represent the majority si ed as internal organ injuries; and 4% fi 17 for injuries in youth baseball, which in- of participants, valid injury risk com- were classi ed as concussions. clude hospital emergency departments, parisons with other age groups cannot Baseball is one of the safest high insurance claims, national catastrophic be directly determined from these raw school sports in the United States with injury reporting system, and indepen- numbers alone. Nearly half of the 3343 a reported injury rate of 1.26 injuries dent researchers.1,10–13 Each of these injuries (44%) involved the head (25% per 1000 athletic exposures.14 Baseball sources captures a limited view of to- to the face, including eyes and nose; athletes have the third lowest rates tal injuries. Taken together, however, 14% to the head and neck; and 5% to of injury lasting longer than 1 week a fairly consistent pattern emerges on the mouth), with the highest frequency among 18 different sports played in the overall injury incidence and rela- in children 9 to 11 years of age.17 Ac- high school. However, although the tive frequency (prevalence) of baseball cording to several years of annual NEISS overall injury rate is low, the degree injuries compared with other sports. reports, approximately one-fourth to one- of injury severity is relatively high. In Comprehensive data also come from third of all youth baseball injuries are to baseball, fractures represent a larger the high school level reporting systems the upper extremities, including the fin- percentage of total injuries than in using certified athletic trainers to re- gers (10%–13%), wrists (4%–5%), and other sports. Baseball also ranks sec- cord the key injury-related information hands (4%–5%). Just under 20% of in- ond highest for the percentage of in- on this 14- to 18-year-old population.14–16 juries were to the lower extremities, with juries resulting in a time loss from knees (5%) and ankles (6%–7%) almost sport participation longer than 7 days.14 Prevalence equally affected. Injuries to the trunk ,15 In high school baseball and softball, The US Consumer Product Safety Com- and pubic area accounted for approx- as in youth baseball, most injuries to mission (CPSC) maintains the National imately 6% to 10% of all injuries.1,11,17 the head and face (48%) and mouth

PEDIATRICS Volume 129, Number 3, March 2012 e843 Downloaded from www.aappublications.org/news by guest on September 25, 2021 and teeth (16.0%) are attributed to 5. Batters are most frequently injured died), nonfatal (athlete left with per- being hit by a batted ball.14 More of by a pitched ball (and by a foul ball manent disability), and serious (athlete these head and facial injuries also re- as they get older). The younger the experienced severe injury but recov- quired surgery (18.0%), compared with batter, the more likely they are to ered, to be left with no permanent other baseball-related injuries (6.8%). be injured by a swung bat of another functional disability).12 The National USA Baseball, through its Medical and player while getting into position. Ap- Amateur Baseball Catastrophic Injury Safety Advisory Committee, sponsored proximately 10% of batting injuries Surveillance Program data revealed an injury-surveillance research and pro- among older batters are of a noncon- annual fatality rate of 0.05 per 100 000 duced a report on injury patterns in tact nature, indicating some form of participants, 0.03 for nonfatal cata- youth baseball in 2008 which concluded overswinging resulting in an injury strophic injuries and 0.04 for serious that, in younger players, injuries are to the muscles, bones, or connective catastrophic injuries.18 Between 1996 more often associated with lack of skill, tissues of the rib cage. and 2006, deaths in youth baseball whereas in older players, the greater 6. Injuries to base runners occurred averaged just over 2 per year.18 These skill, muscle power, and body size be- almost equally at all bases, with deaths occurred from impact to the come injurious forces.13 More detailed slightly more injuries at home plate head resulting in intracranial bleeding fi study findings were as follows: than at rst base. Two-thirds of and from blunt chest impact, likely these injuries occurred from sliding, 1. Across all age groups, pitchers, prompting ventricular fibrillation or and one-third occurred from base catchers, and fielders have a relative asystole (commotio cordis).11,12 running. Base running injuries are frequency of injury in a season com- not related to age, occurring almost Another study based on statistics parable to batters and base runners, 11 equally from collisions, being hit by compiled by the CPSC indicated that with one exception: as age increases, a thrown ball, or simply running there were 88 baseball-related deaths the proportion of injuries to catch- (such as falling, stepping wrong on (approximately 4 per year) to children ers increases, whereas the propor- the base, or straining a muscle). 5 to 18 years old between 1973 and tion of injuries to fielders decreases. 1995.11,19 The injury causing death in 7. Fielder injuries occur at the base 38 cases (43%) was direct-ball impact 2. The younger the age group, the more (33%), in foul territory (10%), and with the chest (commotio cordis); in frequently injuries occur during prac- in the field (57%). Younger fielders tice sessions, not games. Also, in are more likely to be hit by a bat- 21 cases (24%), the injury causing younger age groups, relatively higher ted ball, whereas older fielders death was direct-ball contact with the frequencies of injuries came from are more likely to be injured by head; in 13 cases (15%), the injury “ ” before/after baseball play, such as colliding with a sliding opponent. causing death was from impact from warm-ups or postgame horseplay. bat contact; in 9 cases (10%), the injury causing death was from direct contact 3. Pitcher injuries are also age-related, Catastrophic Injuries with noncontact overuse injuries in- with a ball impacting the neck, ears, or Research from the National Amateur creasing in each older age group. throat; and in 7 (8%), the injury causing Baseball Catastrophic Injury Surveil- Younger pitchers are more likely to death was unknown.11,19 lance Program places the rate of cata- be hit by a batted or thrown ball. Among high school baseball athletes strophic injury very low, at approximately (with approximately 475 000 partici- 4. Catchers principally are injured in 1 injury per 1 million participants an- catchingapitch,gettinghitbyafoul nually. Such injuries may be caused by pating annually), there have been 10 “ ” “ ” tip, or tagging a base runner. Youn- trauma related to participating in the direct deaths, 14 indirect deaths, ger catchers are more frequently skills of the sport, such as contact with 17 nonfatal catastrophic injuries, and injured trying to catch the pitched a bat, baseball, or softball (direct cata- 22 serious catastrophic injuries be- ball, whereas older catchers are strophic injury), by a body system failure tween 1982 and 2008.12 Direct injury more likely to be injured by foul tips. resulting from exertion while partici- rates are between 2 and 5 times Although home-plate collisions dur- pating in a sport or activity (eg, cardiac greater in high school than in youth ing a tag play generate a modest but collapse or heat stroke) or by a com- baseball (5–14 years of age) and 4 constant pattern of injury for catch- plication that resulted from a nonfatal times greater in college than high ers of all ages, these collisions pro- injury (indirect catastrophic injury). Ca- school baseball (but still less than 1/ duce a greater injury risk to the tastrophic injuries are further classified 100 000 participants annually in any of older catcher. according to outcome as fatal (athlete the 3 categories).

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Among high school softball athletes school athletes as a baseline in the 5-year period from the 2005–2006 (371 000 annual participants), there concussion management programs. to 2009–2010 school years. The rate of has been 1 direct death, no indirect Presumably, these are skills that can concussions for baseball was 0.2 per deaths, 2 nonfatal catastrophic inju- be improved marginally with proper 1000 athletic exposures, and for soft- ries, and 1 serious catastrophic injury training and sufficient repetitions. It is ball the rate of concussions was 0.5 per inthe15seasonsfrom1993and estimated that 400 milliseconds is re- 1000 athletic exposures. Of the 9 sports 2008; these rates are approximately quired for a pitcher to complete a surveyed (including football, wrestling, one-tenth of those for high school protective movement, such as lifting a soccer, and basketball), baseball had baseball.12 hand to the chest or face; this corre- the lowest rate, and softball was sev- sponds to a batted ball speed of 42 m/ enth. The top 2 activities associated with second.27 Because balls hit from some concussion in high school boys playing Commotio Cordis metal bats may exceed 42 m/second, baseball were batting (36.7%) and run- Young baseball and softball players performance standards for composite ning the bases (21.5%), whereas for who receive direct ball impact to the metal bats were developed in 2003 to girls playing softball, the top 2 activities anterior chest wall over the cardiac limit their capacity to transfer force were catching (33.3%) and fielding silhouette may develop cardiac arrest. (velocity) to the batted ball. (25.0%).29 The most recent concus- Commotio cordis is the second highest It is noteworthy that cardiac death sion recommendations, including the cause of death in athletes younger caused by commotio cordis is poten- AAP Clinical Report published in 2010, than 14 years and is considered to be tially preventable. If cardiac arrest stress removing an athlete suspected only a pediatric problem because of its occurs, an immediate and appropriate of sustaining a concussion from play unique occurrence in children, usually response may, in many cases, save immediately with no return to play on younger than 16 years.20–22 Children 5 to a young player’s life. AEDs are be- the day of injury. Resting the brain is 14 years of age may be uniquely vul- coming more prevalent in the sports the key to the most rapid resolution nerable to this blunt chest impact, be- world at athletic complexes and cer- of the concussion; such rest includes cause their chest walls are more elastic tainly in patrol cars and emergency no physical activity, with minimal cog- and more easily compressed.20–24 medical vehicles. The use of these nitive and social activity. The concussed Although protective gear can be a key devices, along with cardiopulmonary athlete should seek prompt medical preventive measure, it is not always resuscitation, has become a standard attention from an appropriate health effective. Research has shown that first step in treating cardiac arrest.6,28 professional. Once the athlete is even with protective gear, the fatality If no AED is available near the affected fully free of symptoms and cleared rate for commotio cordis is alarmingly child, the emergency medical care by a physician knowledgeable in the high at 90%.19–24,25,26 Proper coaching system should be activated by using treatment and management of con- and execution can augment protective 911 to get an AED to the athlete’s side cussion, the athlete should enter equipment. Batters who learn to avoid as soon as possible (ideally within 3 a graduated return-to-play protocol the ball and turn away from an inside minutes). Baseball coaches should be to ensure a safe return to sporting pitch can greatly reduce their risk. routinely reminded to have a local activity.30 This is particularly difficult, however, cellular phone and emergency medi- while bunting and, thus, requires cal numbers at every youth baseball Summary of Acute Injuries special attention and instruction. The and softball game and practice in the risk to pitchers can also be reduced event of a medical emergency. Although the rates of injury for base- by teaching proper fielding position ball and softball are low in comparison after ball release as well as ball avoid- with other sports, the combination of ance when necessary.19 The capac- Concussion relatively high severity of injuries that ity to recognize that a batted ball is Concussion in sports continues to do occur and the very large number of coming at you quickly and the ability garner ever-increasing public attention participants in these sports produces to react to that event before the ball and concern. Data on high school con- a substantial number of individuals arrives are crucial traits for protect- cussion rates in baseball and softball with significant injuries each year. ing these athletes. Speed of process- were generated through the Reporting Focused media attention on these ing and reaction time are commonly Information Online system, developed cases often produces a groundswell measured during the computer-based from the National High School Sports- for action, even when the scientific neuropsychological tests given to high Related Injury Surveillance Study, over evidence for change is lacking.

PEDIATRICS Volume 129, Number 3, March 2012 e845 Downloaded from www.aappublications.org/news by guest on September 25, 2021 OVERLOAD CAUSING OVERUSE extremity. The scapula is attached to spines than the opposite side) are INJURY OF THE SHOULDER AND the distal end of the clavicle by the noted on inspection. Observing an ath- ELBOW IN BASEBALL broad acromioclavicular ligament and lete (from behind) performing the arm “ ” Overuse arm injuries in youth baseball the 2 coracoclavicular ligaments that component of a jumping jack ap- primarily affect pitchers. The repetitive arise from the hooklike coracoid. The proximately a dozen times will de- stress of throwing can lead to muscle clavicle attaches proximally to the monstrate poor movement patterns, or fatigue and then to muscle, tendon, sternum at the sternoclavicular joint; scapulothoracic dyskinesis. A second the sternoclavicular joint is the only test entails forward flexing the arm to and ligament damage. To control the joint connection of the entire upper the fully overhead position and slowly number of these injuries, it is critical extremity to the main skeleton of the lowering the arm 180 degrees to its that pediatricians, coaches, athletes, body. The scapula rests on the thorax natural position. Scapulothoracic dys- and parents understand the anatomy, (chest wall) and is connected through kinesis consists of unsmooth or uncon- biomechanics, and kinetics of throw- numerous muscles (scapulothoracic trolled scapular motion while bringing ing a baseball pitch.31–33 joint) that permit the shoulder blade to the arms up or down, including marked In throwing, especially pitching, the rise (shrugging shoulders), to glide scapular winging during descent. Al- arm force and speed generated during around the body (protraction), and to though the athlete may perform the the full windup motion is astonishingly glide back toward the spinal column first few repetitions well, scapulothoracic high(7200degrees,or20revolutionsof (retraction). Strength and endurance dyskinesis may become evident to- a circle, per second for professional of these extrinsic shoulder girdle mus- ward the end of the set, when fatigue pitchers). At ball release, the rotator cles, especially the serratus anterior, sets in.36,38 cuff muscles and long head of the bi- are essential to ensure safe pitching. The scapula also forms part of the gle- ceps contract to decelerate arm motion These muscles must move the scapula nohumeral joint (true shoulder joint). and prevent the arm from following the to its appropriate position and stabilize The scapula’s glenoid is a shallow ball (“throwing one’sarmout”).34 its base before the acceleration phase of socket surrounded by a cuplike rim The shoulder girdle (including the cla- the throwing motion can proceed. With called the labrum, which provides ad- vicle [collarbone], scapula [shoulder excellent scapular muscular control, the ditional stability. The 2 main ligaments blade], glenohumeral joint, humerus, athlete can then use the long lever of of the glenohumeral joint perform most and all of the various muscular attach- the upper extremity to throw with of their stabilizing function when the ments to the thorax and scapula) permits power, speed, and accuracy.36 shoulder is not being used dynamically. the arm to enjoy remarkable freedom of It also has long been recognized, how- During sporting activity and especially movement. Greater joint range of mo- ever, that the source of power (velocity) during throwing, the 4 rotator cuff tion sacrifices the inherent joint sta- in throwing is part of a larger kinetic muscles and the long head of the bi- bility that is usually provided by bony chain, which begins in the legs, travels ceps are responsible for keeping the articulation or ligamentous limitation. through the pelvis into the torso (“the humeral head in the glenoid socket. Unlike other joints, such as the knee core”), and finally comes out through The larger muscles (deltoids, trapezius, and ankle, the glenohumeral joint of the the scapula into the upper extremity. pectorals, latissimus dorsi, short head shoulder acquires nearly all of its Strong legs and especially a strong of the biceps, and triceps) provide the stability during activity from the mus- core help generate a majority of the powerful dynamic forces to move the cles of the shoulder with little or no force behind a pitched ball.37 arm and generate ball velocity. assistance from bones or ligaments. Relative weakness of the serratus an- The term “Little League shoulder” Therefore, when the muscles become terior muscle is often responsible for refers to the widening of the proximal fatigued (and cannot do their job injuries to the rotator cuff muscles, humeral physis resulting from chronic properly), the shoulder becomes an biceps, and elbow (farther down the recurrent traction stress across the unstable joint. Pitchers who continue to kinetic chain). Scapular winging (being growth plate. This lesion is felt to be throw when the arm is fatigued risk able to slide one’s hand under the primarily the result of throwing a large serious and possibly permanent injury medial or inferior edge of the scapula number of pitches or maximum-effort to their muscles, ligaments, capsules, when relaxed), scapular depression throws or insufficient rest between labra, and bones.35 (inferior pole sits lower than the other pitching assignments, but can also The scapula plays a critical role in the side or below T-7), and protraction be related to improper mechanics or functioning kinetic chain of the upper (sits farther away from the vertebral premature attempts with certain pitch

e846 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from www.aappublications.org/news by guest on September 25, 2021 FROM THE AMERICAN ACADEMY OF PEDIATRICS types. When unrecognized, or when pitching limits for a season and a cal- muscles (scapular stabilizers) also recognized in an advanced stage of endar year, based on age.42 In 2007 may help reduce throwing injuries. A overuse, Little League shoulder can and 2008, on the basis of extensive prospective epidemiological research lead to chronic pain with throwing, research, Little League Baseball re- study among asymptomatic adoles- early shoulder instability, or degen- leased its pitch count regulation guide cent and preadolescent tennis athletes erative arthritis.39 in an attempt to reduce the risk of found those with decreased scapula The term “LittleLeagueelbow” refers to overuse injuries to elbows and should- stabilizing muscular strength (noted by medial elbow pain in skeletally imma- ers.43,44 This guide for parents, coaches, scapula winging, protraction, and de- ture athletes resulting from throwing and league officials sets a maximum pression) demonstrated a higher rate issues similar to those mentioned in number of pitches to be thrown in of shoulder injury during the subse- the description of “Little League shoul- a day on the basis of age as well as quent season.47 der.” Pitchers are most likely to be af- the number of rest days between Teaching proper pitching mechanics fected by this condition, but it can also pitching assignments on the basis of may also prevent serious overuse occur in other players at positions re- number of pitches thrown and age. injuries.35,42,43,48 Allowing sufficient time quiring frequent and forceful throwing. It replaces the previous regulations, during the early part of the season Traction forces occur on the medial which set a maximum number of to gradually increase the amount and elbow and compression forces laterally. innings pitched in a calendar week. intensity of throwing may provide The medial traction forces can cause Beginning in 2010, Little League tour- young arms an opportunity to adapt separation or avulsion of the humeral nament pitching regulations became to the stresses of throwing. During medial epicondyle apophysis and over- the same as for regular season play, the off-season and preseason, after use injury to the common flexor ten- as shown in Tables 1 and 2.44,45 It allowing for a period of several months don. The compression forces laterally is the responsibility of the coach to of complete rest from throwing, daily can cause collapse and deformity of know when an athlete has reached his throwing of a strictly limited number the distal humerus (capitulum), also or her pitch count limit. When pitch- of pitches may enhance strength de- known as osteochondritis dissecans in ers exceed recommended pitch count velopment (as regular strength train- adolescents and Panner disease in maximums for age for an entire sea- ing does for other muscle regions) children younger than 10 years. Early son or a full year, the injury rates for with little risk of overuse injury or recognition of symptoms is important shoulders and elbows increase dra- fatigue.35,49 A core-stabilizing exercise to avoid chronic elbow pain, instability, matically.41 program will improve strength and 35 and arthritis. The inability to fully Young pitchers should avoid pitch- should also be adopted for pitchers straighten the elbow is usually an in- ing on multiple teams with over- and hitters.35,37,47 dication of an overuse elbow injury. lapping seasons; the guidelines for Four keys to successful pitching within Complete tears of the ulnar collateral rest requirements must be enforced the 5- to 14-year age group are (1) ligament (UCL) are repaired by “Tommy across all teams. Youth pitchers should the development of a fastball; (2) ac- John” surgery, which is followed by not pitch competitively in more than 8 curacy of locating pitches (control); nearly a year of rehabilitation before months in any 12-month period; 3 return to pitching is allowed. UCL tears (3) development of an off-speed pitch consecutive months of complete rest have risen to nearly epidemic pro- (change-up); and (4) changing pitch from pitching each year is recom- portions in the past 5 years among speeds and plate locations to keep mended. A pitcher should also not be youth and high school pitchers, in- batters guessing. Conventional wis- a catcher for his or her team. Catchers creasing almost 20-fold from the pre- dom has long considered the curve throw even more frequently than vious decade.35,40 When the pitch velocity ball and slider to be stressful to the pitchers, and although the return exceeds 80 miles per hour, the forces young elbow, and recommendations throws are only moderately stressful, experienced at the UCL are near the to delay their introduction until later catchers also make many hard throws point of failure (32 Newton meters).35,41 years (when the skeletal maturity is to the bases during a game. Thus, more significantly advanced) were playing both positions greatly increa- common.43 Recent studies challenge Prevention of Shoulder and Elbow ses the repetitive stress to the arm.35,46 those theories and indicate that, when Overuse Injuries in Baseball A preseason conditioning program that properly thrown, the curve ball may In 2006, the Medical and Safety Advi- includes strengthening the core, the not overly stress the elbow.35,50,51 sory Committee of USA Baseball set rotator cuff, and the shoulder-stabilizing Nevertheless, on the basis of those

PEDIATRICS Volume 129, Number 3, March 2012 e847 Downloaded from www.aappublications.org/news by guest on September 25, 2021 TABLE 1 Little League Baseball 2010 demonstrate injury patterns similar to softball windmill pitch, especially dur- Pitching Guidelines: Maximum baseball with several minor variations. ing the single-leg support component; Pitches per Game One unique feature of softball, however, however, the site of failure (injury) may 10 y and younger 75 pitches per d 11–12 y 85 pitcher per d is the nature of pitching; pitchers throw notbelocatedwheretheproblem 13–16 y 95 pitches per d underhand from a flat mound. Although originates, but at a more remote site 17–18 y 105 pitches per d the softball windmill pitching motion (the weakest link). This kinetic chain Source: Little League (http://www.littleleague.org/media/ may be less stressful to the pitcher’s theory produces “culprits” and “vic- newsarchive/2009/Sep-Dec/LLTournamentRegularSeason- PitchingRulesMadeSame.htm). shoulder and elbow than throwing tims” in describing injuries. For ex- a hardball overhand, there are still ample, although 70% of 131 injuries to significant forces placed on various collegiate softball pitchers were from studies that show increased injury body structures to cause overuse injury. overuse, only 13% were reported in among those who throw curve balls the lower extremity.55 The majority and sliders at early ages, researchers The same concerns exist for arm occurred in the shoulder or elbow. currently continue to recommend de- safety: do not throw when fatigued. As Thus, although the “culprit” may be laying introduction of the curve ball of 2011, inning limitations and rest weak gluteal muscles and lack of pel- until after age 14 or when pubertal days for softball windmill pitchers in vic stabilization, the athlete may pres- development has advanced to the stage the various age divisions of Little ent with shoulder pain, because the when the athlete has started to shave League apply to tournament play only. “victim” shoulder is inherently “the (sliders should be delayed until age Many softball teams rely on fewer weakest link.” 16).41 The American Academy of Pedi- pitchers per team than baseball. Be- atrics endorses this recommendation. fore such inning limitations, some The pelvis and torso work to accelerate Finally, on the basis of the increasing pitchers pitched in multiple games the segments of the upper extremity in number of elbow ligament surgeries in during weekend tournaments, running a sequential manner. Scapular retrac- younger and younger pitchers, it is up pitch counts between 1500 and 2000 tion is stimulated by ipsilateral hip ex- clear that players, parents, and coaches pitches in a 3-day period.52 tension and trunk extension. A stable require more respect for the limits of The driving force of the windmill scapula is vital for optimal rotator cuff the developing child’s arm to withstand softball pitch is in the lower body53;1 function that helps to keep the humerus the forces incurred while pitching and study reported more than 50% of the in the glenoid fossa (thus avoiding im- should understand that the conse- total kinetic energy of upper extremity pingement). quence of overload causing overuse during overhead movements is sup- Accordingly, examination and treatment injuries which can permanently dam- plied by the trunk and legs.54 The of shoulder pain in softball windmill age anatomic structures.35 softball pitcher engages the gluteal pitchers should include an assessment muscles to achieve stabilization of the of and rehabilitation for pelvic stability OVERUSE INJURY FROM SOFTBALL pelvis, which in turn helps the scapula and gluteal strength. Scapular stabi- PITCHING achieve adequate control. lization must also be evaluated and Data on softball injuries were included in The lower extremity supports the me- treated as well as the affected shoulder the previous sections; in general, these chanics of the upper body during the or elbow. Off-season and preseason conditioning programs for softball windmill pitchers should include glu- teal strengthening and pelvic stabili- TABLE 2 Little League Baseball 2010 Pitching Guidelines: Rest Requirements for Pitchers zation exercises. Pitchers 14 y and younger 66 or more pitches in a day Four (4) calendar days 51–65 pitches in a day Three (3) calendar days 36–50 pitches in a day Two (2) calendar days of rest must be observed ROLE OF EQUIPMENT IN INJURY 21–35 pitches in a day One (1) calendar day of rest must be observed RISK AND PREVENTION 1–20 pitches in a day NO (0) calendar day of rest must be observed Pitchers 15–18 y Playing Equipment 76 or more pitches in a day Four (4) calendar days 61–75 pitches in a day Three (3) calendar days The game of baseball requires playing 46–60 pitches in a day Two (2) calendar days of rest must be observed equipment (ball, bat, gloves, bases), as – 31 45 pitches in a day One (1) calendar day of rest must be observed well as equipment to dress and protect 1–30 pitches in a day NO (0) calendar day of rest must be observed Source: Little League (http://www.littleleague.org/media/newsarchive/2009/Sep-Dec/LLTournamentRegularSeasonPitching- the athlete. Although there are over- RulesMadeSame.htm). arching concerns about equipment

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performance and safety that apply to communication, 2009).11,13 Approximately Little League International has im- every athlete who plays baseball, some one-third of baseball-related eye injuries posed a moratorium on the use of concerns typically apply to only a small result from being struck by a pitched composite bats for all baseball divi- segment of players depending on age, ball; other common causes of eye inju- sions citing research that found that developmental level, and skill.56,57 ries are attempting to field a batted ball “composite bats, while they meet the The ball is the cause of most baseball or catch a thrown ball. standard when new, can exceed that ”67 injuries, through being hit by a pitched The composition of the bat has pro- standard after a break-in process. ball, being struck while attempting to voked much discussion in recent years, Although the media continue to report fi field a batted ball, trying to catch especially for baseball players older anecdotal stories of signi cant head a thrown ball, or being hit by a thrown than 15 years. Composite (metal) and facial injuries associated with or batted ball while running the bases. bats have largely replaced wooden metal bats, epidemiological injury Accordingly, modifications in the hard- bats.62 Initially, the introduction of surveillance studies do not show an ness and compressibility of baseballs metal bats led to an increased velocity increase in the rate of such injuries 62 (and softballs) were developed by of the batted ball, putting fielders since metal bats were introduced. equipment manufacturers several dec- at greater risk of injury, especially Equipment-related injuries also in- ades ago for use by children of different pitchers and third basemen.62 Consid- clude those caused by bases and ages with the intent of reducing the erable research has been conducted cleats. Foot and ankle injuries occur force of impact by the ball while comparing both types of bats, but no regularly in baseball and softball, es- maintaining adequate performance consensus exists regarding safety of pecially during sliding. Early studies characteristics; they were known as composite metal bats compared with showed that at least 35% of all injuries reduction-in-force balls. These softer wooden bats in youth baseball.62,63 All in softball occurred while sliding feet fi balls, however, are alleged to possess bats, wooden or metal, are momen- rst into a base, and, in one study, 82% amore“lively” bounce than traditional tarily deformed upon contact with the of those injuries resulted in ankle 68,69 baseballs.56–58 The National Operating baseball; the recoil or restitution fractures or dislocations. Subse- Committee on Standard for Athletic characteristics of the bat to its usual quently, a 2-year study comparing Equipment (NOCSAE) has developed shape result in imparting additional traditional stationary bases and ba- standards for these softer baseballs velocity to the batted ball. Industry ses capable of disengaging noted a greater than 95% reduction in foot (levels 1, 2, and 3),59,60 and an expert performance standards for composite and ankle injuries with breakaway review panel and other researchers metal bats were developed in 2003 bases.70–74 In 2008, Little League base- have indicated that softer balls meet- through the leadership of the National ball and softball mandated the use of ing the NOCSAE standard are less Collegiate Athletic Association and breakaway bases.74 Youth softball lea- likely to cause injury, specifically se- National Federation of State High School gues have also incorporated the use rious head injury or commotio cordis Associations. These standards limit the of a separate “runner’sbase” at first by impact.22–24,60,61 Children with the dimensions of the bat and its capacity base to avoid collisions; the orange lowest skill level (in general, those to transfer force (velocity) to the batted “runner’sbase” sits adjacent to the younger than 10 years) should use the ball (ball exit speed ratio). Bat compo- white regular base, but in foul terri- lowest-impact NOCSAE-approved balls sition for National Collegiate Athletic tory, providing the runner and fielder (level 1). Level 2 low-impact balls are Association baseball was required to separate, equal-size bases. Metal spikes designed for children 10 to 12 years of fi meet the Batted Ball Coef cient of are dangerous to basemen covering age with moderate skill levels. Chil- Restitution guidelines in 2011, and bases; rubber spikes are preferred for dren younger than 10 years of age high school baseball will follow suit in youth baseball. with moderate skills may use either 2012.64 For Little League Baseball, the level 1 or level 2 balls. Level 3 balls maximum bat length is 33 inches and Protective Equipment are designated for youths older than maximum barrel diameter may not Protective equipment should always be 12 years and those 10 to 12 years of exceed 2 1/4 inches. Since 2009, all properly fitted, well maintained, and age with advanced skills.61 Little League bats must be labeled with clean; equipment hygiene is important Baseball has the highest number of a bat performance factor of 1.15 or to prevent infections, such as methicillin- sports-related eye injuries in children, lower.65,66 Bat performance factor is resistant Staphylococcus aureus.Al- with the highest incidence in 5- to 14- a measure of a nonwood bat’sperfor- though not all equipment adaptations year-olds (T.J. Schroeder, MS, personal mance relative to wood bats. For 2011, have been tested scientifically for

PEDIATRICS Volume 129, Number 3, March 2012 e849 Downloaded from www.aappublications.org/news by guest on September 25, 2021 efficacy, experts believe those mentioned running the bases. The NOCSAE de- their good eye when fielding the ball in this article will help reduce injuries in veloped standards for helmets and by using polycarbonate sports gog- softball and baseball players.24 their testing decades ago.59 Their de- gles that meet American Society of Padded sliding pants worn underneath sign and characteristics have been Testing and Materials standard F803.86 the baseball pants provide good pro- modified over the years to better Some parents may also prefer the use tection against contusions and abra- protect the eyes, ears, face, mouth, of a face guard or eye goggles when sions to the hips and thigh when and nose.78 In 2009, a new batting their children are in the field. All ath- athletes slide feet first into a base. For helmet was introduced with the ca- letes who wear glasses or sunglasses athletes who slide head and hands pacity to withstand the impact of a while playing baseball or softball should first, wearing gloves can reduce hand 100-mph fastball; it has a layer of make sure that the lenses and frames abrasions; similarly, use of batting expanded polypropylene, the hard, meet appropriate safety standards, thus gloves improves the grip on the bat foamlike material used in bicycle minimizing the risk of breaking or and reduces the risk of blisters. Head- helmets.79,80 shattering on contact with a baseball 86 first sliding creates the risk of head Face and eye protection can be ach- or softball. injuries from collisions with the fielder ieved by securing additional protection An essential piece of equipment for all or from being hit by a thrown ball; to the batting helmet, such as a poly- boys playing baseball or softball is use upper-extremity injuries can occur carbonate plastic face guard, metal of a hard plastic athletic cup to protect from the contact and deceleration cage, or a polycarbonate full-face the testicles. Although catchers, pitch- forces that occur when the hands of shield. Although full plastic face shields ers, and infielders are at the greatest the diving body encounter the sta- have been demonstrated to reduce in- risk, testicular injuries can occur to any tionary base. According to current jury risk significantly, their acceptance player while in the field, batting, or Little League Baseball rules, a runner by players and league officials has been running the bases. may not slide head-first except when mixed, primarily because of compro- The development of triangular-shaped retreating to a previously held base.75 mised visibility through the shield over foam pads (“knee savers”)forcatch- Chest protectors for batters were in- time.56 More recent epidemiological ers is another advance in safety equip- troduced in the 1990s to protect the research among high school baseball ment that has enjoyed widespread use heart from ball impact, which can athletes has led to a call for infielders since its introduction.87 These pads fit cause commotio cordis.19 However, and pitchers to wear face shields.14 into the popliteal fossa behind the this protective barrier has not been Eye protection may be worn to reduce knee and are designed to minimize shown to be reliable in either the the risk for eye injury.81–84 This pro- the strain on the knee joint while the human experience or in animal labo- tection may be particularly important catcher is in the crouched position. ratory studies.22–25,28,63 More study is for young athletes who have un- Some batters opt for shin guards to required to develop and target equip- dergone eye surgery or experienced protect their medial distal tibia; an- ment that will better prevent commotio a previous serious eye injury.85 Poly- other innovation gaining notice is the cordis.24 Recent design modifications carbonate face guards and shields elbow protective pad for batters. indicate that progress is being made, must meet the F910 standard of the ENVIRONMENTAL RISKS but these advances have not been American Society of Testing and Ma- validated in evidence-based peer- terials.84,86 Face guards cover the Environmental risks include weather- reviewed scientific journal articles or lower part of the face from the tip of related concerns and field conditions abstracts presented at professional the nose to below the chin, directly and boundaries (perimeters). meetings.76 Even the chest protectors protecting the teeth and facial bones; Baseball and softball players are at for catchers, which are effective for the space between the top of the risk for injury from weather-related blunting the usual forces encountered guard and the brim of the helmet is factors, including lightning, sun, and from pitches, foul tips, throws, and less than the diameter of a baseball, heat. Recreational facilities managers, collisions do not reliably prevent com- thereby indirectly protecting the eyes coaches, and umpires need to be well- motio cordis.24,77 without impairing vision. Functionally versed in lightning safety guidelines5,88 Hard plastic shell batting helmets have one-eyed athletes (best corrected vi- and prepare an emergency action long been an integral part of pro- sion in the worse eye of less than 20/ prevention plan in advance. In par- tecting baseball and softball players 50) must use one of these protectors ticular, lightning presents a unique from head injuries while batting and when batting and also must protect challenge because of the difficulty in

e850 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from www.aappublications.org/news by guest on September 25, 2021 FROM THE AMERICAN ACADEMY OF PEDIATRICS predicting and appreciating the pres- game times altered when weather con- including the use of batting tee, a ence of electrical storms. More and ditions are extreme. pitching machine, or an adult pitcher. more facilities are installing auto- Fields need to be inspected regularly The avoidance of head-first sliding for matic lightning detectors and alarm for hazards, including problems with children younger than 10 years is systems to ensure that everyone re- sprinkler heads, gopher holes in the especially important, because there sponds appropriately to the pres- outfield, or rocky infields. A warning have been anecdotal reports of rare ence of lightning. In the absence of an track (usually 15 feet wide) should but serious cervical spine injuries automated warning system, estimating surround the entire grass or artifi- occurring when a young player slides the distance of the storm from the cial turf playing surface and should head-first, hitting an opponent with fields can be accomplished by counting meet all recommended specifications; the top of the helmet. This injury is the number of seconds between seeing the change in surface texture serves similar to that caused by “spearing” lightning and hearing thunder. Divide to alert fielders that they are nearing (using the head as the lead object) in the number of seconds by 5 to estimate the perimeter barriers, such as when football. Feet-first sliding should be the distance in miles. A “flash-to-bang” outfielders are going back on long hits taught consistently (as players be- of 30 seconds or less is an indication to to the fence. All fences should be in come developmentally ready) so that move athletes and spectators to a good repair, especially the backstop all players become comfortable with safe area. A preassigned individual and the fence along both foul lines. If this key technique of the game. The should be responsible for the decision a chain-link fence is curled up and the use of softer balls, as described in to evacuate. In general, a period of 30 grass becomes high, an athlete may a previous section of this statement, minutes should elapse from the last receive a laceration when reaching is also recommended in this age sound of thunder and from the last down to pick up the ball (not noticing group to reduce serious impact injury. visible lightning flash before play the hazard produced by the defective Youth baseball has long recognized should be resumed. fencing). that the game must be modified to Hot and/or humid weather conditions Elimination of the on-deck circle, meet the developmental level and pose significant risk for heat-related placing dugouts behind a fence, and skills of its players. The distance be- illness in children and adolescents. the wearing of batting helmets by the tween bases begins at 45 feet for Tee Ambient temperature, relative humid- first-base and third-base coaches have Ball, moves to 60 feet for Minor League ity, wind speed, and solar radiant heat further reduced the risk of injury on and Little League (Majors) for ages 10 all affect risk for heat illness.89,90 The the playing field. to 12 years, goes to 70 to 75 feet for ability to dissipate body heat into the ages 13 to 15 years, and eventually surrounding environment decreases DEVELOPMENTAL advances to 90 feet for boys 16 to 18 as the ambient temperature rises CONSIDERATIONS years of age; similarly, the pitcher’s closer to body temperature. Similarly, The pediatrician needs to have an mound increases from 46 feet, to 50 as the humidity rises and the air understanding of developmental con- feet, to 60.5 feet from home plate, becomes more saturated with water, siderations as they apply to baseball respectively. The distances of the the ability to cool oneself through and softball participation at various outfield fences also grow as the field evaporation decreases. Wind and sun ages. This will allow the pediatrician to enlarges. The length and weight of exposure can damage the skin and offer appropriate counseling and guid- bats is another variable that changes eyes. Being acclimatized to the envi- ance to the many boys and girls, their as the youth grow in size, strength, ronment, ensuring adequate hydration, parents, and members of the sporting and ability. wearing a baseball cap, and having community who participate in baseball Some children are able to track ball a covered dugout are important fea- and softball each year. movement at early ages and can ac- tures of minimizing the risk of sun- and Compared with older players, children curately move to and catch a fly ball or heat-related illness. Recommendations between 5 and 10 years often have less hit live pitching as early as 5 years old; regarding sunscreen, sunglasses, and coordination, slower reaction times, most children, however, do not achieve proper uniforms for practice and games a reduced ability to pitch accurately, these capabilities until ages 8 or 9.91 are appropriate for players of all ages. and a greater fear of being struck Therefore, it is appropriate to begin Similarly, in cold weather, athletes need by the ball.91,92 Some developmentally introduction to baseball batting for to be properly dressed. When neces- appropriate rule modifications, there- 5- to 7-year-olds using a ball that is sary, games should be postponed or fore, are advisable for this age group, not moving but placed on a tee. For

PEDIATRICS Volume 129, Number 3, March 2012 e851 Downloaded from www.aappublications.org/news by guest on September 25, 2021 children who are capable of hitting guidelines regarding the number be properly fitted, well maintained, a thrown pitched ball, however, being of pitches thrown daily; (b) rest and clean. forced to hit the tee ball may not en- requirements between pitching 5. Current data show that chest bar- hance their skill development. assignments; and (c) season and riers or protection are not suffi- Coaches who are not knowledgeable in yearly total pitch limits.38,42,44 Young ciently effective in preventing child development may become frus- pitchers should avoid pitching on commotio cordis; thus, the rou- trated trying to teach basic skills to multiple teams with overlapping tine use of these heart protectors young boys and girls who are simply seasons; the guidelines for rest is not recommended for baseball not ready to acquire these skills, no requirements must be enforced players at this time. Catchers matter how many balls are pitched to across all teams. Youth pitchers must continue to wear approved them or how many fly balls they are should not pitch competitively in chest protectors. asked to catch during practice. For more than 8 months in any 12- 6. Coaches and officials must be pre- these reasons, Little League baseball month period; 3 months of rest pared to activate the emergency tracks its athletes into the minors and from pitching are recommended response system (call 911) and the majors for boys 10 through 12, each year. A pitcher should also to obtain rapid access to an AED, separating those children who are not be a catcher for his or her ideally in less than 3 minutes, to developmentally advanced from those team. assist young baseball or softball who are developing at the typical rate. 3. Parents, coaches, and players players who are experiencing car- It must be remembered, however, that should be educated about the diac arrest or another medical “late bloomers” may ultimately turn early warning signs of elbow emergency. Coaches should have out to be the finest athletes of all, and shoulder overuse injuries as a local cellular phone and emer- despite their slower beginning. Proper well as the importance of para- gency medical phone numbers instruction and persistent repetition in scapular muscle strength. Athletes available for use at all times. the fundamentals of baseball are es- should cease pitching immediately 7. Coaches, parents, umpires, and sential for youth to develop the talent when signs of arm fatigue or pain league officials need to be knowl- and skills required to perform pro- occur; they should be encouraged edgeable regarding the cause, pre- ficiently at a high level during late to seek timely and appropriate vention, recognition, and response adolescence and adulthood. treatment of significant or persis- to concussion. New policies exist tent pain.35 RECOMMENDATIONS with excellent free educational and 4. Serious and potentially catastrophic prevention materials, especially The American Academy of Pediatrics baseball injuries can be minimized from the Centers for Disease Con- recommends the following: by the proper use of available trol and Prevention. Furthermore, 1. Because baseball and softball for safety equipment. This safety equip- free on-line trainings are available children 5 through 18 years of ment includes: (a) for hitters, ap- through the Centers for Disease age are relatively safe sports, proved batting helmets with face Control and Prevention (http://www. participation should be encour- protection; (b) for catchers, hel- cdc.gov/concussion/) and the Na- aged by pediatricians. mets, masks with throat guards, tional Federation of State High 2. Preventive measures should be chest protectors, and shin guards; School Associations (www.nfhs.org). used to protect young baseball (c) for all male players, hard plastic 8. Youth baseball and softball play- pitchers from throwing injuries. athletic cup; and (d) for all baseball ers should wear polycarbonate Adequate core strength and scapu- and softball players, rubber-spiked eye protection guards or shields lar muscle strength provide a crit- soles. In light of the relatively high or metal cages on their batting ical foundation; proper instruction percentage and severity of head, helmets to reduce the risk of in throwing mechanics, condition- face, and mouth injuries in baseball, eye injury. For functionally one- ing, and training is another essen- strong consideration should be eyed athletes (best corrected vi- tial component. Delay introduction given to head and facial protec- sion in the worse eye of less than of the curve ball until after age 14 tion for pitchers and infielders, 20/50) and those who have under- and the slider until age 16. Three especially in younger age groups gone eye surgery or experienced key elements in preventing overuse and for less-skilled players. Pro- previous severe eye injuries, eye injuries in pitchers include: (a) age tective equipment should always protection (one of the 3 types of

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face shields or polycarbonate When necessary, games or practi- Holly J. Benjamin, MD sports goggles) should be required ces should be postponed or game Charles T. Cappetta, MD Rebecca A. Demorest, MD at all times while the athlete is bat- times altered when weather condi- Mark E. Halstead, MD ting or fielding. tions are extreme. Chris G. Koutures, MD 9. Children with the lowest skill level 12. Protective fencing of dugouts and Cynthia R. LaBella, MD Michele Labotz, MD (in general, those younger than benches and the elimination of the Keith J. Loud, MDCM, MSc 10 years of age) should use the on-deck circle are recommended Stephanie S. Martin, MD lowest-impact NOCSAE-approved during games and practices in or- Amanda K. Weiss Kelly, MD balls (level 1). Level 2 low-impact ganized and informal participation. balls are recommended for chil- Proper field maintenance is re- PAST COUNCIL EXECUTIVE dren 10 to 12 years of age with quired to minimize injury risks. COMMITTEE MEMBERS Joseph A. Congeni, MD moderate skill levels. Children 13. New developmentally appropriate Andrew J. M. Gregory, MD younger than 10 years with mod- rule modifications should con- Stephen G. Rice, MD, PhD, MPH erate skills may use either level 1 tinue to be implemented when in- or level 2 balls. Level 3 balls are dicated. LIAISONS Lisa K. Kluchurosky, MEd, ATC – National Athletic designated for youths older than 14. Surveillance of baseball and soft- 12 years and those 10 to 12 years Trainers Association ball injuries should be continued. John F. Philpot, MD – Canadian Paediatric So- of age with advanced skills. Continual strong support of re- ciety 10. Continued research into the rela- search is essential to develop Kevin D. Walter, MD – National Federation of State High School Associations tive safety of composite metal ver- other new, improved, and effica- sus wooden bats is appropriate cious safety equipment and rule PAST COUNCIL EXECUTIVE LIAISON fi and necessary. modi cations. Claire M. A. LeBlanc, MD – Canadian Paediatric 11. Awareness of heat and lightning Society LEAD AUTHORS safety is essential for all coaches Stephen G. Rice, MD, PhD, MPH and officials of Little League base- Joseph A. Congeni, MD CONSULTANTS ball and softball. The Web site Michael F. Bergeron, PhD COUNCIL ON SPORTS MEDICINE AND Robert Cordes, MD http://www.lightningsafety.noaa. James Raynor, MS, ATC 88 FITNESS EXECUTIVE COMMITTEE, gov/outdoors.htm and weather 2010-2011 forecasts are critical resources Teri M. McCambridge, MD, Chairperson STAFF for prevention of lightning injuries. Joel S. Brenner, MD, MPH, Chairperson-Elect Anjie Emanuel, MPH

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Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. Pediatrics is owned, published, and trademarked by the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2012 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

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