The Pediatric Athlete

General Principles

  • A pediatric athlete can be any child or adolescent usually under the age of 18 years who participates regularly in sports activities.

  • Understanding physical and physiologic differences between pediatric and adult patients aids in the prompt recognition and management of most medical and orthopedic conditions affecting a pediatric athlete.

  • Activity type, skill level, and motivation for sports participation greatly vary at different ages and levels of maturity; therefore, it is best to understand young athletes in the context of their chronologic age, developmental stage, and physical maturity, coupled with an assessment of the nature and level of sports participation.

  • It is important to understand both the child’s and parent’s motivation for sports participation and to capitalize on opportunities to educate parents, athletes, and coaches on healthy athletic participation and sports safety.

  • Sports specialization is defined as intense activity in only one sport throughout the year. Avoiding early sports specialization may decrease the risk of injury, overtraining, and burnout.

  • The ultimate goal of youth sports participation should be the promotion of lifelong physical activity, pursuit of recreation, and enjoying the challenge of competition.

  • Healthcare professionals face challenges at both ends of the physical activity spectrum: the sedentary obese child, who faces a lifetime of morbidity related to physical inactivity, and the highly competitive, overzealous, often anxious, and potentially undernourished young athlete are both at risk for a myriad of injuries associated with sedentary behaviors or excessive exercise. A successful pediatric athlete will lead a healthy, balanced lifestyle and integrate exercise, nutrition, and recreational pursuits with an adequate amount of rest and recovery.

Medical Concerns of the Pediatric Athlete

  • Several conditions that affect pediatric athletes are similar to those that affect adult athletes. Examples include cardiac conditions (e.g., cardiac arrhythmias), pulmonary conditions (e.g., asthma), mental health conditions (e.g., eating disorders and stress/anxiety/depression), endocrine disorders (e.g., diabetes and obesity), renal conditions (e.g., polycystic kidney disease), and infectious diseases (e.g., community-acquired methicillin-resistant Staphylococcus aureus [CA-MRSA], HIV, mononucleosis, and coronavirus-19 [COVID-19]).

  • Prompt recognition and management of these conditions may lead to safe and early return to sports.

  • A preparticipation physical examination (PPPE) (refer to Chapter 3 ) is recommended for pediatric athletes before organized sports participation. It is usually a state-mandated legal requirement for participation in high school interscholastic athletics.

  • The PPPE is a helpful tool for physicians to identify medical conditions that may affect participation in sports and physical activity.

Exercise and the Pediatric Athlete

  • According to 2018 guidelines from the US Department of Health and Human Services, children ages 6 to 17 years should engage in 60 minutes of physical activity every day, which should include 3 days per week of vigorous-intensity, muscle- and bone-strengthening activities. These guidelines also suggest that children ages 3 to 5 years should try to obtain 180 minutes of physical activity throughout each day.

  • Suggestions to encourage physical activity:

    • Limit or reduce sedentary time (television, computer, video games, and phone) to 30 minutes/day outside of mandatory school computer time.

    • Find fun activities that children enjoy.

    • Incorporate parent role models.

    • Emphasize the social aspect of participating in team sports.

    • Promote the use of activity trackers (step counters, wireless trackers, wearables, etc.).

  • There are numerous benefits of exercise in pediatric patients ( Box 10.1 ).

    BOX 10.1
    Common Benefits of Physical Activity in Children and Adolescents

    • Weight control

    • Lowers blood pressure

    • Raises high-density lipoprotein (HDL) or “good” cholesterol

    • Reduces risk of diabetes

    • Improves self-esteem

Physicians, Patients, and Exercise

  • The 2017 Youth Risk Behavior Survey from the Centers for Disease Control and Prevention (CDC) revealed that only 26.1% of high school–aged students reported levels of physical activity consistent with current guidelines for physical activity.

  • Additionally, recent research has shown that only 23% of family physicians and only 33% of pediatricians were able to correctly identify physical activity guidelines for children aged 6–18.

  • The activity prescription “MD FITT” is a useful tool for guiding and tracking physical activity ( Table 10.1 ).

    Table 10.1
    Description of “MD FITT” Exercise Prescription
    M–MODE What type of activity (e.g., walking or biking)
    D–DURATION For how long does the patient exercise daily?
    F–FREQUENCY How often does the patient exercise (days/week)?
    I–INTENSITY How intense is the exercise (e.g., moderate)?
    T–TIMELY FOLLOW-UP How often the patient revisits the clinician
    T–THERAPY Are there any concerns of injury or side effects?

Childhood Obesity

  • Obesity is the most important health concern among children in the United States.

  • The prevalence rate of obesity in children is 11%–22%, and it has doubled in the past 20 years.

  • Childhood obesity is increasing at an epidemic rate, particularly in economically disadvantaged areas and minority populations.

Age Range: Preschool Through High School

  • Preschoolers spend approximately 11% of their time in vigorous activities, 60% in sedentary activities, and an average of 3–5 hours/day watching television.

  • Every hour of television is associated with a 2% increase in obesity risk.

Risks of Adult Obesity

  • Fifty percent of children who are obese at the age of 6 years are likely to remain obese in adulthood.

  • Seventy to 80% of children who are obese at the age of 10 years are likely to remain obese in adulthood.

  • Additional risk is associated with concurrent parental obesity: 23% of all deaths in the United States are associated with sedentary lifestyles that begin in childhood.

Body Mass Index (BMI) in Children

  • BMI = [weight (kg)]/[height (m) 2 ]

  • A child with a BMI in the 85th to 95th percentile is considered overweight and at risk of obesity.

  • A child with a BMI in the 95th percentile and above is considered obese.

  • Annual BMI calculation is recommended for children during routine and sports physical examinations and can be followed longitudinally. Pediatric growth charts based on age and gender include BMI and are available online ( ). Numerous electronic medical record (EMR) systems calculate BMI when height and weight measurements are entered.

Causes of Childhood Obesity

  • Energy intake is routinely greater than energy expenditure.

  • Endocrine, hormonal, and genetic syndromes can each cause or contribute to obesity in children.

Complications of Childhood Obesity

  • Any and all organ systems in the body can be affected by childhood obesity: cardiac, orthopedic, endocrine, gastrointestinal, respiratory, and neurologic systems are among those most often affected.

Treatment Recommendations

  • Assessment of energy intake and output, physical examination, and laboratory evaluation to exclude other causes of obesity, as well as providing nutritional and exercise education.

  • Nutritional interventions include changes in advertising, healthy school lunches, and adequate and varied healthy food choices in the home environment.

  • Exercise recommendations include increased recreational activities, organized sports participation, preservation of adequate physical education time in school, and decreased sedentary screen time (e.g., computer and television).

  • A meta-analysis of 30 randomized controlled trials in children aged 5–17 years found that low-intensity, long-duration exercise coupled with resistance training was highly effective in altering and improving body composition.

Growth and Maturation and the Young Athlete

  • Concerns regarding potential negative effects of athletic competition on growth and maturation have existed for many years, particularly attributable to the trend of intense competition at younger ages.

    • The demands of sports require a certain level of physical and psychological maturity in order to participate. Feelings of insecurity, frustration, and failure may cause young athletes to quit because of burnout or inability to perform up to expectations.

    • While young athletes are struggling to master advanced sports-specific skills, their coaches may be less experienced and less educated in appropriate training techniques; these barriers can negatively affect a young athlete’s enjoyment and participation in his or her sport(s).

  • A significant challenge for sports medicine healthcare providers is the consideration of the development of the neurologic, cognitive, somatic, and psychological interdependent processes and the effects of each of these on the health and well-being of pediatric athletes.

    • An understanding of fundamental principles of normal child and adolescent growth and development is essential in providing quality healthcare for young athletes.

  • Growth and maturation is a natural, fundamental, continuous process, with achievement of the same milestones in the same order.

    • The rate of progression varies greatly and seems predominantly genetically regulated.

    • Neuropsychological development often does not parallel physical development.

    • Growth refers to an increase in size of the body and its parts, including stature, body systems, and body composition.

    • Maturation refers to a biologically mature state of skeletal, sexual, and somatic development with variable timing and tempo.

    • Neurodevelopment is culturally mediated and is the acquisition and mastery of behavioral competence.

    • Quantitative milestones are easy to measure by the number of skills performed.

    • Qualitative milestones are harder to measure because they reflect mastery of specific skills.

Neurodevelopmental Domains

  • Motor: fine and gross motor, strength, and endurance

  • Visual: acuity, discrimination, and tracking

  • Cognitive: attention, alertness, memory, comprehension, and solving complex problems or simultaneously performing multiple tasks

  • Language: receptive and expressive

  • Auditory: hearing acuity and processing, sound discrimination, and auditory cues

  • Emotional and psychological: relationships with teammates and coaches and regulation of emotions

  • Motor: fine and gross, visual-spatial discrimination, temporal sequencing, proprioception, sports-specific motor adaptive skills, muscular strength and endurance, and reaction time

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