Over the past few decades, cheerleading has evolved from leading the crowd in cheers at football games to a competitive, year-round sport featuring complex acrobatic stunts performed by a growing number of athletes- and as a result the number and severity of injuries from cheerleading has also surged.

In a new policy statement, the American Academy of Pediatrics (AAP) urges coaches, parents and school officials to follow injury-prevention guidelines, develop emergency plans and ensure cheerleading programs have access to the same level of qualified coaches, medical care and injury surveillance as other sports.

"Cheerleading has become extremely competitive in the past few years, incorporating more complex skills than ever before," said pediatric sports medicine specialist Cynthia LaBella, MD, FAAP, member of the AAP Council on Sports Medicine & Fitness and co-author of the new guidelines. "Relatively speaking, the injury rate is low compared to other sports, but despite the overall lower rate, the number of catastrophic injuries continues to climb. That is an area of concern and needs attention for improving safety."

The policy statement, "Cheerleading Injuries: Epidemiology and Recommendations for Prevention," will be released at a news conference at 9 a.m. Monday, Oct. 22, at the AAP National Conference & Exhibition in New Orleans and published in the November 2012 issue of Pediatrics (published online Oct. 22).

Although most high schools and colleges have cheerleaders, only 29 state high school athletic associations recognize cheerleading as a sport, and the National Collegiate Athletic Association (NCAA) does not include competitive cheerleading in its list of sponsored sports. This is important, according to the AAP, because being classified as a sport gives athletes valuable protection including qualified coaches, well-maintained practice facilities, access to certified athletic trainers, mandated sports physicals and surveillance of injuries.

From 1990 to 2003, the number of U.S. cheerleaders age 6 and older increased by roughly 600,000, from 3 million to 3.6 million. Since 2007, there are 26,000 cheerleading injuries in the U.S. annually. Cheerleading accounts for 66 percent of all catastrophic injuries in high school female athletes over the past 25 years.

Most injuries are sprains and strains to the lower extremities, followed by head and neck injuries.

Cheerleading can include fast-paced floor routines and physically demanding skills, including pyramid building and lifting, tossing, and catching athletes in the air. These stunts account for 42 percent to 60 percent of all injuries, and 96 percent of all concussions. Cheerleading is one of the highest risk sporting events for direct catastrophic injuries that can result in permanent brain injury, paralysis or death.

Risk factors for cheerleading injuries include previous injury, cheering on hard surfaces, higher body mass index, performing complicated stunts, and inadequate coaching. As in other sports, cheerleading injury rates increase with competition level and age. Collegiate cheerleaders have a higher rate of injury than middle and high school competitors.

"Most serious injuries, including catastrophic ones, occur while performing complex stunts such as pyramids, according to Jeffrey Mjaanes, MD, FAAP, FACSM, member of the AAP Council on Sports Medicine & Fitness and co-author of the new guidelines. "Simple steps to improve safety during these stunts could significantly decrease the injury rate and protect young cheerleaders."

The AAP makes key recommendations for preventing injuries, including:

    Cheerleading should be designated as a sport in all states, allowing for benefits such as qualified coaches, better access to medical care and injury surveillance.

    All cheerleaders should have a pre-season physical, and access to qualified strength and conditioning coaches.

    Cheerleaders should be trained in all spotting techniques and only attempt stunts after demonstrating appropriate skill progression.

    Pyramid and partner stunts should be performed only on a spring/foam floor or grass/turf. Never perform stunts on hard, wet or uneven surfaces. Pyramids should not be more than 2 people high.

    Coaches, parents and athletes should have access to a written emergency plan.

    Any cheerleader suspected of having a head injury should be removed from practice or competition and not allowed to return until he or she has clearance from a health professional.