AMERICAN ACADEMY OF PEDIATRICS Committee on Sports Medicine and Fitness Risk of Injury From Baseball and Softball in Children ABSTRACT. This statement updates the 1994 American their thoraces may be more elastic and more easily Academy of Pediatrics policy statement on baseball and compressed.2 Statistics compiled by the US Con- softball injuries in children. Current studies on acute, sumer Product Safety Commission1 indicate that overuse, and catastrophic injuries are reviewed with em- there were 88 baseball-related deaths to children in phasis on the causes and mechanisms of injury. This this age group between 1973 and 1995, an average of information serves as a basis for recommending safe about 4 per year. This average has not changed since training practices and the appropriate use of protective equipment. 1973. Of these, 43% were from direct-ball impact with the chest (commotio cordis); 24% were from direct-ball contact with the head; 15% were from ABBREVIATION. NOCSAE, National Operating Committee on impacts from bats; 10% were from direct contact with Standards for Athletic Equipment. a ball impacting the neck, ears, or throat; and in 8%, the mechanism of injury was unknown. INTRODUCTION Direct contact by the ball is the most frequent aseball is one of the most popular sports in the cause of death and serious injury in baseball. Preven- United States, with an estimated 4.8 million tive measures to protect young players from direct Bchildren 5 to 14 years of age participating an- ball contact include the use of batting helmets and nually in organized and recreational baseball and face protectors while at bat and on base, the use of softball. Highly publicized catastrophic impact inju- special equipment for the catcher (helmet, mask, ries from contact with a ball or a bat frequently raise chest, and neck protectors), the elimination of the safety concerns. These injuries, as well as ongoing on-deck circle, and protective screening of dugouts concerns about shoulder and elbow injuries, provide and benches. the impetus for this review of the safety of baseball for 5- to 14-year-old participants. The discussion fo- cuses principally on baseball, but softball is consid- OVERUSE INJURIES ered in accord with the availability of relevant liter- The term “Little League elbow” refers to medial ature. This statement mainly concerns injuries elbow pain attributable to throwing by skeletally during practices and games in organized settings. immature athletes. Pitchers are most likely to be Players and bystanders also can be injured in casual affected by this condition, but it can occur in other play. positions associated with frequent and forceful throwing. The throwing motion creates traction INJURY OVERVIEW forces on the medial portion of the elbow and com- The overall incidence of injury in baseball ranges pression forces on the lateral portion of the elbow. between 2% and 8% of participants per year. Among The medial traction forces can cause separation or children 5 to 14 years of age, an estimated 162 000 avulsion of the apophysis from the medial epicon- baseball, softball, and tee-ball injuries were treated in dyle of the humerus and overuse injury to the com- emergency departments in 1995. The number of in- mon flexor tendon. The compression forces laterally juries generally increased with age, with a peak in- can cause collapse and deformity of the distal hu- cidence at 12 years. Of the injuries, 26% were frac- merus, also known as osteochondritis dissecans of tures, and 37% were contusions and abrasions. The the capitulum of the humerus. Early recognition of remainder were strains, sprains, concussions, inter- the symptoms is important to avoid chronic elbow nal injuries, and dental injuries.1 The potential for pain, instability, and arthritis. catastrophic injury resulting from direct contact with In response to concerns about Little League elbow a bat, baseball, or softball exists. Deaths have oc- and shoulder, many youth leagues have attempted curred from impact to the head resulting in intracra- to limit the stress placed on the pitching arms of nial bleeding and from blunt chest impact, probably youth. For example, Little League Baseball Incorpo- causing ventricular fibrillation or asystole (commotio rated limits pitchers to a maximum of 6 innings per cordis).1 Children 5 to 15 years of age seem to be week and requires mandatory rest periods between uniquely vulnerable to blunt chest impact because pitching appearances.3 The number of pitches thrown per outing should be recorded for all young pitchers. Recommendations include limiting the The recommendations in this statement do not indicate an exclusive course number of pitches to 200 per week, or 90 pitches of treatment or serve as a standard of medical care. Variations, taking into 4 account individual circumstances, may be appropriate. per outing. A preseason conditioning program that PEDIATRICS (ISSN 0031 4005). Copyright © 2001 by the American Acad- includes strengthening the rotator cuff and the emy of Pediatrics. shoulder-stabilizing muscles also may help reduce 782 PEDIATRICS Vol.Downloaded 107 No. 4from April www.aappublications.org/news 2001 by guest on September 29, 2021 throwing injuries. Instruction on proper pitching me- anecdotal reports of rare but serious cervical spine chanics is another way to prevent serious overuse injuries occurring when a player slides head-first, throwing injuries.5 Finally, allowing time during the hitting an opponent with the top of the helmet. This early part of the season to gradually increase the injury is similar to that caused by spearing (using the amount and intensity of throwing may allow young head as the lead object) in football. Such sliding arms a better opportunity to adapt to the stresses of should be banned for players younger than 10 years. throwing. Much of the injury research has concerned baseball and is not differentiated between baseball and soft- EQUIPMENT ball. Injury risks seem to be similar in softball. There- fore, the same recommendations for injury preven- Modifications in the hardness and compressibility tion in baseball apply to softball except for of softballs and baseballs have been developed for limitations on pitching. use by children of different ages with the intent of reducing the force of impact while maintaining per- formance characteristics. The National Operating RECOMMENDATIONS Committee on Standards for Athletic Equipment The American Academy of Pediatrics recommends (NOCSAE) has developed standards for these softer the following: baseballs.6 An expert review indicated that softer 1. Baseball and softball for children 5 through 14 balls that meet the NOCSAE standard are less likely years of age should be acknowledged by pediatri- to result in serious head injury or commotio cordis cians as relatively safe sports. Catastrophic and attributable to ball impact.1 chronically disabling injuries are rare; the fre- Chest protectors for batters are a relatively new quency of injuries does not seem to have increased product. They are produced in 2 styles: a small 6 ϫ during the past 2 decades. 6-in polyethylene square intended to protect the 2. Preventive measures should be used to protect heart from ball impact; and a high-density plastic young baseball pitchers from throwing injuries. and foam vest intended to protect the rib cage and These measures include a restriction on the num- the heart and other vital organs. Expert review of the ber of pitches thrown in organized and informal available scientific literature indicated that the way settings and instruction in proper training, condi- in which baseball impact causes death is unknown at tioning, and throwing mechanics. Parents, coaches, the present. Therefore, the effect of any equipment and players should be educated about the early on the risk of chest impact death remains undeter- warning signs of an overuse injury and encour- mined.2 aged to seek timely and appropriate treatment if Concern has been raised about injuries to the evidence of an injury develops. eye.7–9 Baseball is the leading cause of sports-related 3. Serious and potentially catastrophic baseball inju- eye injuries in children, and the highest incidence ries can be minimized by the proper use of avail- occurs in children 5 to 14 years of age. Approxi- able safety equipment. This includes the use of mately one third of baseball-related eye injuries re- approved batting helmets; helmets, masks, and sult from being struck by a pitched ball. As a result, chest and neck protectors for all catchers; and for this age group, Prevent Blindness America has rubber spikes. Protective fencing of dugouts and recommended the use of batting helmets with poly- benches and the use of break-away bases also are carbonate face guards that meet standard F910 of the recommended, as is the elimination of the on-deck American Society for Testing and Materials.10 These circle. Protective equipment should always be cover the lower part of the face from the tip of the properly fitted and well maintained. These pre- nose to below the chin. They also protect against ventive measures should be used in games and injuries to the teeth and facial bones. Functionally practices and in organized and informal partici- one-eyed athletes (best corrected vision in the worst pation. eye of less than 20/50) must use these face guards. 4. Baseball and softball players should be encour- They also must protect their eye when fielding by aged to wear polycarbonate eye protectors on using polycarbonate sports goggles. Eye protection their batting helmets to reduce the risk of eye also may be particularly important for young ath- injury. These eye protectors should be required letes who have undergone eye surgery or experi- for functionally one-eyed athletes (best corrected enced a serious eye injury. vision in the worst eye of less than 20/50) and for athletes who have undergone eye surgery or ex- DEVELOPMENTAL CONSIDERATIONS perienced severe eye injuries if their ophthalmol- Compared with older players, children younger ogists judge them to be at an increased risk for eye than 10 years often have less coordination, slower injuries.