Gaps in E-Bike Regulation Heighten Risks for Young Riders

Electric bicycles (e-bikes) have rapidly emerged as a major source of pediatric injury, with trauma patterns increasingly resembling those seen in motor vehicle collisions.¹

Global e-bike sales were estimated to total 30 million units between 2020 and 2023, reflecting widespread availability and declining cost barriers.² Although precise ridership estimates are not available, observations indicate increased e-bike use among middle- and high-school students.

Pediatric trauma centers are seeing the consequences. Several now report e-bikes as the leading mechanism of injury among school-aged children presenting to emergency rooms (ERs) across the US.

Healthcare providers at Rady Children’s Health in Orange County, California, treated only one pediatric e-bike crash patient in 2021, compared with more than 220 in 2025. At Rady Children’s Hospital in San Diego, California, 446 e-bike patients were treated in 2025, comprising 40% of the institution’s trauma activations. These injuries are not only more frequent, they also are more severe, with patterns that resemble high-energy trauma rather than traditional bicycle crashes.¹

This e-bike injury surge in the US contrasts with trends in Asia, Europe, and the Middle East, where e-bikes were adopted a decade earlier and regulatory changes were made in response to serious injury patterns in both adults and children.

The Mineta Transportation Institute’s 2025 report notes that the US regulatory approach is “by no means common worldwide.”³ In fact, most e-bikes sold in the US would not meet European standards, underscoring the permissive regulatory environment.

US e-bike motors are typically three times more powerful than those allowed in Europe and the rest of the world (750 W versus 250-400 W, respectively). As a result, many US e-bikes would be classified as mopeds elsewhere, requiring minimum age thresholds, maximum speeds, licensure, insurance, and formal safety education. Many countries set a minimum age for e-bike use (often around 16 years of age for devices like US Class 2 e-bikes) and do not allow the use of throttle e-bikes.

In the US, children are allowed to operate devices capable of 20–28 mph—and, when illegally modified, more than 50 mph—without formal training or consistent helmet enforcement.

State policymakers are beginning to respond to this issue, but the pace of policy development lags far behind the rate of adoption. The widening gap continues to expose children to high-energy injury risk.

What Research Shows

More than 150 studies have examined e-bikes, primarily focusing on lower-powered models comparable to US Class 1 e-bikes, and demonstrate a very serious pattern of e-bike-related injury and mortality. A limitation of these studies is the variability in motor wattage and maximum speed permitted across countries.

In a 2-year, Level I US trauma center study published before the pandemic, e-bike injuries accounted for 14% of all pediatric traffic-related hospitalizations.⁴ National Electronic Injury Surveillance System (NEISS) data show a sharp spike in injuries since that time with pediatric e-bike injuries increasing from 4.18% of all recorded cases in 2019 to 49.8% in 2023.² In California, e-bike incidents rose 1,800% from 2018 to 2023.⁵

A 2018 Dutch Level I trauma study found that while e-bikes accounted for only 2.9% of total bicycle crashes, they represented 27.6% of all bicycle-related fatalities nationwide.⁵ Prompted by research showing high-crash risks, Dutch policymakers reclassified e-bikes in 2017. For high-speed e-bikes (up to 28 mph), they mandated a minimum owner age of 16, while restricting standard e-bikes to a 15-mph maximum speed.

A 2019 World Health Organization report described efforts to protect e-bike riders in China, who accounted for 14% of all traffic-related deaths. E-bikes in that country have been limited to a maximum of 16 mph, with a 400-W motor, and a minimum age of 16 to operate in some regions. In addition, e-bikes are banned in many pedestrian throughfares.

Why Children Are at Heightened Risk

High-powered devices, inexperienced riders, and unprotected road environments created a perfect storm for pediatric trauma. The risk factors for pediatric e-bike injuries are multifactorial, and include mechanical, developmental, and environmental factors that extend beyond the risk associated with conventional bicycles.

Mechanical: Speed and Kinetic Energy

E-bikes allow speeds of 20–28 mph with minimal effort; illegal modifications can push speeds past 50 mph.

In a NEISS study, nearly half of speed-related (more than 20 mph) pediatric e-bike injuries involved the head, neck, or face, and 24.1% resulted in internal organ injury—more than double the rate of non-speed-related crashes.² The heavier weight of e-bikes (30–60 pounds) and higher speeds increase kinetic energy and lengthen stopping distance, often beyond what young riders can safely manage.

Low Rates of Helmet Use

Helmet use among injured pediatric e-bike riders remains low. In a neurosurgical series of 20 children with e-bike-related cranial trauma, none wore a helmet.⁶ Another pediatric ER study found helmet use in only 19% of cases.⁷ The predictable result is a pattern of skull fractures, intracranial hemorrhage, and long-term neurologic morbidity.

Developmental Limitations

Children lack the hazard recognition, braking control, and judgment required to safely operate a motor-assisted device. Their limited ability to anticipate traffic behavior is compounded by perceptual errors made by drivers: Motorists underestimate the time-to-arrival of fast-moving e-bikes, increasing the collision risk.⁸

Environmental Factors: Unsafe Infrastructure

Children riding in dense traffic or on rural roads without protected lanes face substantially higher exposure to high-energy collisions. Built-environment studies show that unsafe or unprotected routes increase the likelihood of traffic conflict for school-aged riders.⁹

Injury Patterns Are More Like Motorcycles than Bicycles

Head and Cranial Trauma

Head injuries remain the most devastating category of pediatric e-bike trauma. One study reported that 85% of children with e-bike-related cranial injuries sustained skull fractures, 30% had intracerebral contusions, 15% had epidural hematomas, and 30% had subdural hematomas.6 Nationally, head trauma from e-bike crashes increased 49-fold between 2017 and 2022 across all age groups.¹⁰

Internal Organ Injury and Hospitalization

Internal injuries are increasingly recognized as a hallmark of high-speed e-bike crashes. A study demonstrated that 24.1% of speed-related e-bikes crashes result in internal organ injuries, compared to 10.4% of non-speed-related crashes.² This internal trauma included abdominal and thoracic organ injuries, including splenic lacerations, hepatic injury, and pulmonary contusions. Even low-velocity crashes can result in occult internal trauma when handlebars strike the abdomen or chest.

Orthopaedic Trauma

Orthopaedic injuries are another major component of pediatric e-bike trauma. One study noted 50% of e-bike-injured children sustained skeletal injuries—significantly higher than automobile passengers (24%).⁴

Comparative Severity of E-Bike Injuries versus Non-Motorized Bicycles

Across multiple studies, pediatric e-bike injuries consistently demonstrate greater severity than injuries from conventional bicycles. Children injured on e-bikes are more likely to present with multisystem trauma, higher Injury Severity Scores, and a greater likelihood of requiring operation or intensive care admission.^2,4,6-8

Burn and Electrical Injuries

Lithium-ion battery malfunction introduces a distinct and increasingly recognized category of pediatric e-bike injury not seen with traditional bicycles. E-bikes rely on high-energy rechargeable batteries that can fail, triggering rapid, uncontrolled heating. E-bike battery explosions release toxic gases and may reignite after appearing extinguished. These events can cause deep dermal or full-thickness burns requiring operative management and have caused multiunit housing fires leading to many deaths.⁵

Prevention Strategies

Effective prevention of pediatric e-bike trauma requires a multipronged approach addressing the child rider, device, and environment.

Consistent helmet use remains the most important protective behavior. The Consumer Product Safety Commission (CPSC) recommends a Department of Transportation-approved helmet for bicycles exceeding 20 mph.

Helmet legislation, school-based education, and both law and parental enforcement, along with modeling behavior, are essential to increasing compliance. Training programs that teach braking technique, hazard recognition, and safe riding behavior can help align children’s skills with the performance of the devices they operate. Most importantly, the CPSC recommends that children under 12 years should not operate motorized products that exceed speeds of 10 mph. Recommendations such as this have led some countries to prohibit children under 12 from operating any class of e-bike. 

Device-focused strategies include selecting age-appropriate e-bikes with lower maximum speeds, lower motor wattage, restricting aftermarket modifications, and ensuring that lights, reflectors, batteries, and braking systems are properly maintained.

Environmental strategies—such as protected bike lanes, traffic calming, and safer intersection design—reduce exposure to high-risk traffic. Public health messaging that frames e-bike safety alongside seat belts and car seats may further normalize protective behaviors.

Parents must ensure their children can safely operate a pedal bicycle before advancing to a more powerful e-bike and understand the financial and liability risks if their child damages property or injures others.

Why Legislative Action Cannot Wait

Legislative and regulatory frameworks have not kept pace with the rapid adoption of e-bike use among minors. Many jurisdictions classify e-bikes into tiers based on maximum-assisted speed and throttle capability, but enforcement of age restrictions and speed limits is inconsistent, and high-powered devices remain accessible to children.

The story of Amelia Stafford, a Marin County (California) teenager who sustained a serious e-bike injury, was featured in a July/August 2024 ACS Bulletin article and subsequently in The New York Times. Her story is described as the “crash heard around the country” and galvanized both California and federal-level action, highlighting the power of patient and surgeon advocacy to catalyze legislative change.

California Youth E-Bike Safety Legislation

As of May, three California bills aim to reduce youth injury. AB 2346, sponsored by the California Medical Association, will impose a 15-mph speed limit for riders under age 15 statewide (and a 10-mph limit on sidewalks). AB 2595 will allow San Mateo County cities to require e-bike riders to be at least 12 years old, following similar ordinances in San Diego and Marin counties. SB 1167 will revise the existing vehicle code definition of mopeds or motorcycles to include electric devices with more powerful motors beyond 750 watts and subject them to new disclosures at the point of sale.

California law requires a driver’s license to operate an e-scooter, whose motor ranges from 250-600 W and travels at slower maximum speeds of 15-22 mph. Perhaps a license also should be required for e-bike users. Class 3 e-bikes travel at speeds (28 mph) comparable to mopeds (limited to 30 mph by the Department of Motor Vehicles). Using the name “e-moped” could provide greater clarity to purchasers about Class 3 risks.

In 2026, legislators in New Jersey repealed the three-class e-bike system, and mandated licensure, insurance, registration, education, and a minimum age of 16 to operate an e-bike statewide.

Federal E-Bike Regulation

A fragmented, state-by-state approach is generating confusion for consumers, retailers, and law enforcement. To solve this crisis, we need immediate and comprehensive federal regulation. Convening a national task force to standardize state laws would be another starting point to clarify the current regulatory patchwork.

Fully understanding the problem requires examining its root cause. HR 727, passed by Congress in 2002 defined “low-speed bicycles” as having fully operable pedals, an electric motor less than 750 W (1 horsepower), and a maximum speed of 20 mph. HR 727 declared that e-bikes are not motor vehicles under federal transportation safety standards, placing them instead under the jurisdiction of the CPSC, effectively regulating them as consumer products like tricycles, not motorized vehicles like mopeds.

Congress never anticipated what would happen next. They did not define a “high-speed electric bicycle” or authorize throttle-powered Class 2 e-bikes or the 28-mph Class 3 models. Instead, industry advocacy groups proposed the 3-class system in the mid-2010s during a federal regulatory vacuum, and states adopted it piecemeal resulting in a patchwork of conflicting state laws on age limits, speeds, helmet requirements, and motor wattage.

At the federal level, HR 5265, the SAFE Ride Act of 2025, directs the US Secretary of Transportation to support state grant programs that maintain comprehensive e-bike safety initiatives through the National Highway Traffic Safety Administration. States must create an effective system for enforcing safety requirements governing shared e-bike operations, and ensure operators and users comply with established rules. The states also must make e-bike safety education publicly available and incorporate national curricula into outreach. The ACS Legislative Committee endorsed HR 5265, and an action alert is available at ACS SurgeonsVoice. 

HR 5265 is directionally correct, but more needs to be done. The CPSC should end the deceptive sale of overpowered devices marketed online that exceed legal e-bike specifications. More broadly, Congress should redefine an e-bike as a motorized vehicle, move oversight to the Department of Transportation, and reduce motor power.

Call to Action

The current e-bike safety crisis recalls the early days of mopeds in the 1970s, when regulations struggled to keep pace with their rapid adoption, triggering a strong legislative response.

In 2025, the ACS, American Academy of Orthopaedic Surgeons, and American Association of Neurological Surgeons issued statements to increase public awareness and advocate for legislation to protect e-bike riders. Organizations focused on the health and well-being of children, including the American Academy of Pediatrics, American Medical Association, American Pediatric Surgical Association, and American College of Emergency Physicians, should develop similar policy statements.

The evidence is clear, and one possible solution is to require Class 1 e-bike users to be 12 years and older, while Class 2 and Class 3 e-bike riders must be 16 years or older.

These measures represent early but important steps toward a coordinated safety approach. This long-term effort will require health professionals to partner with school leaders, law enforcement, elected officials, and stakeholders like the Centers for Disease Control and Prevention and US Secretary of Transportation to stem the growing epidemic of youth e-bike-related morbidity and mortality.

Surgeons can advocate at the local, state, and federal levels by meeting with policymakers, attending ACS state advocacy days, submitting editorials to media outlets, and participating in forums and town halls to raise public awareness. The most powerful voices are the young patients who have been injured and their family members, alongside their physicians, calling for change.

Pediatric e-bike injuries represent a rapidly evolving public health challenge. The devices are powerful, widely accessible, and increasingly used by children who lack the ability to safely operate them. The resulting head trauma, internal organ damage, complex fractures, maxillofacial injuries, penetrating trauma, and battery-related burns are severe, costly, and preventable.

Without stronger regulation, the burden of pediatric e-bike trauma will continue to rise. Surgeons are uniquely positioned to advocate for evidence-based policy, including age restrictions, device regulation, and safety education. Decisive action is required to reduce preventable morbidity and mortality while preserving the benefits of e-bikes as a transportation option.

Dr. Romeo Ignacio Jr. is a nationally recognized pediatric trauma surgeon who serves as the trauma medical director at Rady Children’s Health in San Diego, CA.

References

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