From helmets and mouthpieces to elbow pads and shinguards, the sheer amount of protective equipment worn by young sports participants today rivals that of any professional athlete.
It's hard to believe that these kids wouldn't be safe from any impact.
However, according to new research presented today at the American Heart Association's Scientific Sessions in Chicago, all of that gear may not be enough to protect young athletes against sudden death caused by a blow to the chest.
The study found that out of 85 such deaths in organized youth sports, 33 had occurred despite the presence of potentially protective equipment. The average age of these athletes was 15.
The cause of death in these cases is called commotio cordis, a Latin term meaning "commotion of the heart."
It is caused by a blunt, nonpenetrating blow to the chest that triggers an irregular heartbeat called ventricular fibrillation. Collapse and sudden death follow unless medical help is provided immediately.
In sports, the blow can be caused by hard contact with another person -- a common occurrence in sports such as football and hockey. Equipment such as balls, bats, hockey sticks, hockey pucks or other projectiles can also be the source of the impact.
These cases in the study included 14 hockey players, 10 football players, six lacrosse players, and three baseball players.
Ten of these fatalities occurred when projectiles struck the chest protector directly.
"These athletes wore standard, commercially available chest barriers, made of polymer foam covered by fabric or a hard shell, generally perceived to provide protection from the consequences of chest blows," said Dr. Barry Maron, senior author of the study and director of the Hypertrophic Cardiomyopathy Center at the Minneapolis Heart Institute Foundation in Minneapolis, Minn.
"Hopefully, these data will represent a stimulus for developing a truly effective chest barrier that will be absolutely protective against the risk of these commotio cordis catastrophes," Maron said.
"This highlights inadequacies of protective gear in young athletes," said Dr. David Haines, chief of the division of cardiology and director of the Heart Rhythm Center at Beaumont Hospital in Royal Oak, Mich. "I think that these data should stimulate a reevaluation of the design of this gear."
"As a parent, I always assumed that my child was protected on the lacrosse and football fields. Apparently not," Haines said.
An Issue of Timing
Though tragic, the occurrence of commotio cordis in youth sports is rare.
Since 1995, experts say there have only been 182 deaths of youth involved in sports from commotio cordis.
This is largely because the time window in the heart cycle in which the chest impact must occur for the heart to be affected is tremendously short -- about two-hundredths of a second.
"The difference between a benign blow and commotio cordis is timing," Maron said. "If the blow occurs directly over the heart at a particular time in the heart's cycle, the results can be catastrophic."
"The findings come as no surprise to those who understand the ability of a blow occurring in the vulnerable period of the cardiac cycle to cause a lethal arrhythmia," said Dr. Richard Luceri, director of the Arrhythmia Center at Holy Cross Hospital in Fort Lauderdale, Fla.
"Of interest, and not mentioned, is the fact that most cases of commotio cordis result in death regardless of the attempts at resuscitation," Luceri said.
Accidents Will Happen -- but Should They?
Amid the concern over deaths in youth sports, most people would agree that no youth sport is without its dangers -- protective equipment notwithstanding.
"I am not yet convinced that more aggressive maneuvers are needed at this time," said Dr. Brian Olshansky, director of cardiac electrophysiology at University of Iowa Hospitals in Iowa City, Iowa.
"This is a problem, but the risks need to better defined in the general population before going crazy," Olshansky said.
Other experts point out that parents must be careful not to go overboard with worry.
"As a specialist in the field, this interests me, but [it] would probably scare many parents of the hundreds of thousands -- if not millions -- of our youth who engage in sports," Luceri said. "The emphasis should definitely be on the fact that this is rare."
"To be fair to manufacturers, these products were never designed with commotio cordis in mind," Maron said. "We don't know at this point exactly how to design a product that would have specific protection from commotio cordis. I think the information is important from an educational standpoint. Parents have a right to know all the risks of the athletic field in sports participation."
The study is an "important registry," said Dr. Douglas Zipes, distinguished professor emeritus at the Indiana University School of Medicine in Bloomington, Ind.
But he said, "They have been saying that the gear was not protective for some time, so this is not new."
Zipes says continuing research is currently being conducted to experiment with different types of chest protection.
"Until they come up with something new, there really isn't anything to recommend for parents," Zipes said.
The study may also turn an eye toward the availability of automated external defibrillators (AEDs) at facilities hosting youth sports events.
"It is a very rare event, though heart-rending without a doubt," Zipes said. "Having an AED available is best."
However, some experts say better equipment -- and better regulatory oversight -- is also needed to keep the number of these cases to a minimum.
"Commotio cordis is a well-known problem, however, the lack of effective protective gear is previously less well documented," said Dr. Peng-Sheng Chen, director of the Clinical Cardiac Electrophysiology Training Program at Cedars-Sinai Medical Center in Los Angeles.
"Certainly there is room for improvement. I think the FDA [Food and Drug Administration] should demand proper testing of the protective clothing, and that the parents should be advised to purchase only the certified items for their children," Chen said.
"This is a very devastating event for the family affected by this tragedy, and I think that most cases are preventable."