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Position statement

CPS

Improving cycling safety for children and youth

Posted: May 2, 2024

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Principal author(s)

Daniel Rosenfield B.Arts.Sc, MD, MHI, FRCPC, Pamela Fuselli MSc, Suzanne Beno MD FRCPC, Injury Prevention Committee

Abstract

Cycling remains a popular activity for children and youth around the world, combining the fun of moving at speed with numerous health and societal benefits. However, cycling is also associated with risk for serious injury and death. Over the past decade, research has increasingly shown that improving safety for cyclists depends, in large part, on the environment they are cycling in as well as on individual safety measures such as helmet use. The pandemic provided greater opportunity for many children and youth to engage in cycling, and refocused public attention on safer cycling infrastructure such as protected bike lanes. This statement reviews the evidence supporting safer cycling infrastructure for children and youth along with the physical and mental health benefits of cycling. The advantages of active transportation for young people, and how the built environment influences their cycling safety and uptake, are discussed. An overview of measures individuals can take to improve cycling safety is followed by recommendations for clinicians, the cycling community, parents, and policy-makers.  

Keywords: Built environment; Cycling; Head injury; Helmet; Injury prevention

Background

Cycling is a popular activity around the globe. In Canada, many children and youth ride their bikes for pleasure, exercise, and getting to and from school or other activities. However, cycling also poses risks for young people—injuries are common, and deaths can occur. Severe injuries and fatalities typically occur when cyclists are hit by motor vehicles. According to Canadian police-reported collision data, 513 children (aged 0 to 14 years) were seriously injured while cycling, and 4 were killed, in 2020 alone[1]. Injury rates have trended downward since the early 2000s, however. In 2000, for example, 1592 child cyclists were injured, but annual injury numbers have stabilized since, with an average of 566 injuries per year from 2013 to 2020. Similarly, while an average of 14 child cyclists were killed each year between 2001 and 2004, the annual average was 4 deaths from 2005 to 2020. Mortality rates are just the tip of the iceberg, however. The number of children and youth who are affected by cycling-related injuries requiring hospitalization and causing chronic health issues remains significant. For example, cycling injuries were the third-leading cause of unintentional injury-related hospitalizations of children from 2006 to 2011[2].

While cycling remains popular in Canada, overall cycling rates have decreased somewhat across all age groups. The most recent available data, from 2013-2014, showed that 24% of cyclists over 12 years of age reported cycling in the preceding 3 months, compared with 29% in 1994-1995[3]. There are multiple reasons for declining rates, but this statement focuses on the built environment, systems-level infrastructure, and more recent policy choices[4][5] as contributing factors. 

Historically, cycling safety advocates have focused primarily on riders and their responsibilities, with emphasis on wearing a helmet and high-visibility clothing, following rules of the road, and bicycle maintenance as protective and preventive factors. However, research literature over the past decade has shown that while individual factors influence injury frequency and severity, societal systems and choices also determine cycling uptake and safety. The built environment—how streets and neighbourhoods are designed, evolve, and used—plays a central role in keeping all cyclists, and especially children and youth, safer. This statement examines how clinicians, parents, and policy-makers can improve cycling safety for children, youth, and the broader community, by focusing on purpose -built infrastructure alongside strategies that optimize individual safety. 

The benefits of cycling

The health benefits of cycling during childhood are numerous and compelling, with physical fitness being the most robustly researched. Early exposure to and participation in physical activity, including cycling, helps establish positive routines lifelong. People who start cycling early often stay active throughout their adult lives[6], which lowers risk for developing cardiovascular disease, cancer, type 2 diabetes, and other, often chronic, conditions[7]. A child’s first ‘commute’ to school is a key opportunity to establish a healthy, active living pattern, perhaps for life[8]. The evidence is clear that adult commuters who bike to work have a reduced risk of mortality from any cause, and specifically reduced risk of developing cardiovascular disease or cancer[7]. Physical activity in children confers numerous health benefits, including mental health[9], which are discussed below.

Active transportation

Active transportation means getting somewhere using ‘body power’, with cycling and walking as common examples. Driving or busing are passive by contrast. Children and youth who get to and from school and other activities under their own steam experience significant benefits, including greater alertness at school and attention to their surroundings compared with their peers who are driven or bused[10]. They are also in better physical shape and healthier over the longer term[7].

Despite increased vehicular use over the past 50 years and a steady decline in active transportation[11], the most recent available data suggest that one in three children continue to use active transportation to get to school[12]. Multiple factors, including personal (e.g., age, gender, education), psycho-social (e.g., socioeconomic status (SES), perceptions of safety), and environmental (e.g., residential density, distance from school, neighborhood connectivity) context, and local policies (e.g., school boundaries and busing distances)[13]-[15] also help determine transportation to and from school.

A recent, large cross-sectional study showed that active school transportation rates vary widely among large cities in Canada. In Quebec, for example, 40% of children used active transport to get to school in Laval, compared with 70% in Montreal. Within-city variation was even wider. In Montreal, the range was 0 to 96% across the city. The same study associated increased density of cycling infrastructure with higher rates of active transportation among children. Cycling infrastructure effects were the largest in Toronto, Montreal, and Laval, with smaller effects found in other Canadian cities[13]. Research on the built environment tends to focus on urban areas with significant density. No studies exploring use of cycling infrastructure in rural or remote areas of Canada were found.

The built environment

The term ‘built environment’ refers to any human-made area or infrastructure and encompasses land use patterns, streets, sidewalks, and other transportation-related amenities. Rising obesity rates have sharpened the attention of public health policy-makers and community advocates on the role of built environment toward ensuring walkability and cycling capacity within neighbourhoods. Strong correlations exist among obesity rates, SES, and the built environment, such that low walkability scores and lack of cycling infrastructure correlate with increased obesity rates[16][17]. When considering health equity, it is well recognized that the lowest cycling rates are seen in low income, immigrant, and racialized populations[18]. A leading reason why is the poor cycling infrastructure often found in disadvantaged neighborhoods[19][20]. 

Recent studies conducted both in Canada and elsewhere have shown that pedestrian and cyclist safety are closely related to the built environment. Land use and zoning policies play a defining role in cyclist safety. Denser, mixed-use communities lead to shorter trip lengths with concordantly higher cycling rates. When examining cycling-specific infrastructure, one 2020 study showed that increasing the number and connectedness of ‘cycle tracks’ (i.e., dedicated bike lanes) in Toronto improved safety for cyclists significantly[12]. Not only were cyclists more protected in these lanes, but a ‘halo’ effect was also observed: a significant reduction in collisions involving motorists and pedestrians in the 500 m area surrounding these cycle tracks also occurred[21]. In 2021, another Toronto-based study by the same researchers found that when a large proportion of drivers exceeded the posted speed limit in front of elementary schools, this behaviour correlated with decreased rates of active transportation among children and youth[22].

The fact that dedicated cycling lanes decrease injuries has been well established in the literature. One 2013 Cochrane review showed a 50% decrease in collisions involving children in one town when protected bike lanes were built, compared with a comparable town that did not have them[23]. While a variety of bike lane configurations exist (e.g., painted on established roads, protected right of ways, or elevated lanes), one recent study by the Insurance Institute for Highway Safety found that elevated, protected bike lanes were safest[24]. Protected lanes and infrastructure have also been shown to increase the number of cyclists overall[25]. Data from one international study highlighted that rates of female cyclists closely match those of children. Women generally cycle most frequently when and where there is protective cycling infrastructure[26].

Conditions that support safer cycling infrastructure also help to safeguard other outdoor activities for children, specifically by making it safer for them to walk within neighbourhoods. Because walking is the primary active transportation method used by children to get to school, factors besides dedicated cycling infrastructure that increase access and safety, such as crossing guards and traffic signals, are worth noting[13].

Parental perceptions of the local built environment also have a role in determining children’s physical activity levels, including outdoor play, cycling, and active transportation to school. Where parents perceive higher risk, their children’s physical activity levels decrease. Safer environments are associated with more physical activity by children. Designing infrastructure that encourages active transportation will help reassure parents and lead them to relax restrictions around children’s free play, cycling, walking, and other healthy activities[27].

The speed of motorized vehicles is directly associated with risk and severity of collisions. Traffic calming interventions such as speed humps, speed limits, and speed cameras have been shown to effectively reduce speeding, collision, and injury rates[28]-[30]. Other measures include narrowing streets, curb extensions, driver feedback signs, on-street parking, and raised intersections[31]. Such interventions have been shown to improve local perceptions of safety, a correlate of active transportation uptake. Exceptionally, however, any intervention that narrows total available road space and brings cyclists closer to vehicular traffic (compared with narrowing vehicle lanes to increase space for cyclists) often has the opposite effect[32].

The differences between rural versus urban built environments are worth considering, especially as they effect cycling and the active transportation of children to school. Canadian data has shown that built environments in rural areas are generally less favourable to cycling compared with larger Canadian cities, but much more research conducted in a variety of Canadian settings is needed[33].

The cost-effectiveness of cycling infrastructure

Recent economic analyses have confirmed that investing in cycling infrastructure is cost-effective, with public health benefits that consistently outweigh the rising costs of building infrastructure[34][35]. One 2021 study estimated that investment in infrastructure which led to a modest 2% increase in bike use would bring economic benefits worth $116.6 million in Victoria, B.C. and $59.1 million in Halifax, N.S., a benefit:cost ratio of 1.7:1 and 2.1:1 respectively[34]. Local pushback to expanding protected cycle tracks can sometimes speak over the benefits. However, most recent analyses have demonstrated that fears concerning the removal of parking spaces and vehicular custom for curb-side businesses are not borne out. For example, when Toronto installed dedicated cycle tracks on Bloor Street (a main east-west artery through the heart of the city), businesses experienced an increase in both customers and revenue, not a decrease[36].

‘Vision Zero’

Vision Zero is a broad-based strategy to eliminate traffic fatalities and severe injuries completely, with principles that apply to nearly all cycling environments. Initiated by the government of Sweden in 1997, it has been adopted by many others around the world since. In 2017 the European Academy of Paediatrics urged policy-makers to work toward a continent where no child is killed in traffic[37]. Vision Zero combines smart road design, overall system planning, and public policies to improve individual safety. Vision Zero is also being adopted across Canada, with 19 cities and 2 regions from 7 provinces participating. Canada’s largest cities have all signed on, and British Columbia and Manitoba have adopted Vision Zero at the provincial level[38]. While jurisdictions have prioritized different aspects of the strategy and budgets vary, all are committed to its key principles. 

Cycling during and after the pandemic

An unanticipated social effect of the COVID-19 pandemic was that outdoor PA increased for certain populations, most consistently among higher SES householders[39]. Both in Canada and around the world, cycling rates rose dramatically[40][41], and while cycling-related injuries increased, most were not severe[42]. Many cities around the world experimented with, then mandated, permanent cycling infrastructure. In Canada, clear pathways toward implementation are needed to prevent paediatric injury rates from increasing.

Individual actions

Although systems-level infrastructure and built environments are the primary determinants of cycling safety, injury prevention programs and family counselling also have roles. Approximately one-half of children who are admitted to hospital with a cycling-related injury have sustained a severe head injury, and head injuries also represent between 45% and 100% of injuries causing death[43]. The literature is unequivocal that helmet use reduces both the number and severity of head injuries significantly[44]. Two Cochrane systematic reviews demonstrated that helmets reduce risk of head and brain injuries by 69%, severe brain injuries by 74%, and facial injuries by 65% across all age groups[45][46]. A 2018 meta-analysis confirmed these findings, noting a 48% reduction in total head injuries, a 60% reduction in serious head injuries, a 23% reduction in facial injuries, and a reduction in the total number of killed or seriously injured cyclists by 34%[47].


The challenges of increasing helmet use in the paediatric population persist, however. The literature has shown that helmet legislation is not only the most powerful lever that policy-makers have to protect young people[48], but these laws do not discourage or decrease the number of children cycling in jurisdictions where they are passed[49]. Consistently however, the rates of bicycle ridership and helmet use among young people in Canada have been associated most strongly with higher SES[50][51]. There is also an urban versus rural divide, whereby children in rural environments use helmets less than their urban peers[51][52].

Other safety equipment (e.g., wrist guards) have fewer clear benefits. One 2005 study found that wrist guards impeded children’s ability to cycle comfortably and may have limited utility for protecting against injuries sustained during a fall[53].

Training children to anticipate risks and hazards also has challenges. One study found that while young children who participated in safety programs were able to identify dangerous situations better than peers without such training, this awareness did not change their safety behaviours significantly[54]. Many cyclist education programs exist for children in Canada and worldwide, but their effectiveness remains largely unknown because evaluation mechanisms and follow-up have been weak or lacking altogether[55].

Recommendations

The pandemic helped renew public focus on cycling by children and youth as a physical activity to encourage and build for in Canada. The onus of cycling-related injury prevention has shifted somewhat from the individuals engaged in this activity toward the built environment. Local governments must be informed of options that build, expand, and promote safer cycling infrastructure. They must also invest in redevelopment.

With families they see, health care professionals should promote active transportation for children and youth to and from school and advocate for policies that support safer cycling and walking in their communities.

The Canadian Paediatric Society supports safe, active, and equitable cycling for children and youth through enhancing and optimizing the built environment as follows:

  • Install more protected (and ideally, elevated) bike lanes that physically separate cyclists from motorized traffic, and make existing pilot lanes permanent. Focus should be on and around areas of high use by children and youth, especially near schools, community centres, and recreation and play spaces.
  • Deploy more speed and red-light cameras in high traffic areas near schools, busy neighbourhoods, and recreation and play spaces.
  • Implement traffic calming measures where children and youth live, play, and travel to and from school.
  • Adopt ‘Vision Zero’ interventions that increase road safety for all users.
  • Increase helmet use among children and youth through education, legislation, and training programs (with evaluation and follow-up). Mandatory helmet legislation should exist across all provinces and territories and, ideally, for all ages.
  • Target research and advocacy to increase cycling, road safety, and helmet use in rural and remote areas of Canada.

Acknowledgements

The authors wish to thank Adam Rosenfield and Stephanie Cowle for their expert review. This position statement has been reviewed by the Adolescent Health and Community Paediatrics Committees of the Canadian Paediatric Society, as well as by representatives of the Public Health Agency of Canada’s Behaviours, Environments and Lifespan Division.

CANADIAN PAEDIATRIC SOCIETY INJURY PREVENTION COMMITTEE (March 2023)

Members: Dominic Allain FRCPC MD, Emilie Beaulieu MD MPH, Suzanne Beno MD (Chair), Jeff Critch MD (Board Representative), Kristian Goulet MD, Daniel Rosenfield MD, Maaz Mirza (Resident Member)        

Liaisons: Andre Champagne (Public Health Agency of Canada), Pamela Fuselli (Parachute - Leaders in Injury Prevention), April Kam MD (CPS Paediatric Emergency Medicine Section)

Principal authors: Daniel Rosenfield B.Arts.Sc, MD, MHI, FRCPC, Pamela Fuselli MSc, Suzanne Beno MD FRCPC

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Disclaimer: The recommendations in this position statement do not indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate. Internet addresses are current at time of publication.

Last updated: May 3, 2024

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