General Principles
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A pediatric athlete can be any child or adolescent usually under the age of 18 years who participates regularly in sports activities.
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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.
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Activity type, skill level, and motivation for sports participation greatly varies 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.
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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.
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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.
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The ultimate goal of youth sports participation should be the promotion of life-long physical activity, pursuit of recreation, and enjoying the challenge of competition.
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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, 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
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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., mononucleosis).
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Prompt recognition and management of these conditions lead to safe and early return to sports.
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A preparticipation physical examination (PPE) (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.
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The PPE is a helpful tool to help physicians identify medical conditions that may affect participation in sports and physical activity.
Exercise and the Pediatric Athlete
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According to the American Heart Association, children and adolescents should participate in at least 60 minutes of moderate to vigorous activity daily.
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Multiple small periods of activity, such as two 30-minute periods or four 15-minute periods of exercise, are acceptable alternatives.
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Suggestions to encourage physical activity:
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Limit or reduce sedentary time (television, computer, video games, and phone) to 30 minutes/day.
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Find fun activities that children enjoy.
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Incorporate parent role models.
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Emphasize the social aspect of participating in team sports.
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Promote the use of activity trackers (step counters, wireless trackers, etc.).
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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 HDL or “good” cholesterol
Reduces risk of diabetes
Improves self-esteem
Physicians, Patients, and Exercise
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A recent study found that approximately 47% of primary care physicians self-report the inclusion of exercise history during patient examinations.
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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 re-visits the clinician
T-THERAPY
Are there any concerns of injury or side effects?
Childhood Obesity
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Obesity is the most important health concern among children in the United States (US).
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The prevalence rate of obesity in children is 11%–22%, and it has doubled in the past 20 years.
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Childhood obesity is increasing at an epidemic rate, particularly in economically disadvantaged areas and minority populations.
Age Range: Preschool Through High School
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Preschoolers spend approximately 11% of their time in vigorous activities, 60% in sedentary activities, and an average of 3–5 hours/day watching television.
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Every hour of television is associated with a 2% increase in obesity risk.
Risks of Adult Obesity
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50% of children who are obese at the age of 6 years are likely to remain obese in adulthood.
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70%–80% of children who are obese at the age of 10 years are likely to remain obese inadulthood.
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Additional risk is associated with concurrent parental obesity: 23% of all deaths in the US are associated with sedentary lifestyles that begin in childhood.
Body Mass Index (BMI) in Children
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BMI = [weight (kg)]/[height (m) 2 ]
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A child with a BMI in the 85th to 95th percentile is considered overweight and at a risk of obesity.
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A child with a BMI in the 95th percentile and above is considered obese.
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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 ( www.cdc.gov/growthcharts ). Numerous EMR systems calculate BMI when height and weight measurements are entered.
Causes of Childhood Obesity
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Energy intake is greater than energy expenditure.
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Endocrine, hormonal, and genetic syndromes can each cause or contribute to obesity in children.
Complications of Childhood Obesity
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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
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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
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Nutritional interventions include changes in advertising, healthy school lunches, and adequate and varied healthy food choices in the home environment.
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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).
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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
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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.
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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.
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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).
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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.
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An understanding of fundamental principles of normal child and adolescent growth and development is essential in providing quality healthcare for young athletes.
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Growth and maturation is a natural, fundamental, continuous process, with achievement of the same milestones in the same order.
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The rate of progression varies greatly and seems predominantly genetically regulated.
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Neuropsychological development often does not parallel physical development.
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Growth refers to an increase in size of the body and its parts, including stature, body systems, and body composition.
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Maturation refers to a biologically mature state of skeletal, sexual, and somatic development with variable timing and tempo.
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Neurodevelopment is culturally mediated and is the acquisition and mastery of behavioral competence.
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Quantitative milestones are easy to measure by the number of skills performed.
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Qualitative milestones are harder to measure because they reflect mastery of specific skills.
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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
Motor Developmental Milestones in Various Age Groups
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Understanding developmental milestones from infancy through young adulthood is essential in successfully caring for the constantly growing pediatric athlete.
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It is difficult to “skip” major neuromuscular milestones during periods of growth; however, the rate at which young athletes progress is sometimes accelerated.
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Accelerated motor development can be problematic if the young athlete is not psychologically or emotionally ready to fully function at this new level of expectation and skill.
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Healthcare professionals should be familiar with the sequence of skill acquisition that is predictable among various young athletes.
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Preschoolers (4–6 years)
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Ride bike without training wheels
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Hop six times on one foot
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Catch a small ball thrown from 10 feet
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Run, gallop, and skip using alternating feet
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Broad jump up to 3 feet
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Throw a ball with a shift of their bodies at a target
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Move from parallel play to interactive play with others
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Middle Childhood (6–11 years)
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Gender differences can be observed.
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Girls excel at hopping, skipping, catching, and balance.
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Boys excel at striking objects, jumping (vertical and long), kicking, and throwing and can run faster.
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Implications for Sports Participation in Young Athletes
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Coach and parent reaction with appropriate feedback is crucial in sports development.
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Confidence, self-esteem, and body awareness are all developing.
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Young athletes should be taught to think “I’m learning and improving” rather than “I can or can’t”.
Gender Differences
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In preadolescents, there is little difference in strength, power, and endurance between boys and girls.
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Girls are consistently more flexible.
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Boys are consistently better throwers.
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Power and maximal oxygen uptake (VO 2 max) increase linearly with age until adolescence when it accelerates. However, in adolescent boys, accelerated rate gains far exceed than those seen in adolescent girls and are partly a result of increased muscle mass in such boys.
Neuropsychological and Emotional Readiness
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Peer relationships with teammates involve the ability to take turns, attend to the game, focus, and participate in teamwork.
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The coach–athlete relationship requires the ability to follow rules, understand strategies, and control emotions.
Implications for Organized Sports Participation
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Physical maturation is necessary to master sports-specific skills.
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Neurodevelopmental maturation allows simultaneous functional integration of multiple skills to meet the demands of the competition.
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Motor: e.g., a soccer player needs to simultaneously run and kick in a coordinated fashion
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Visual: monitor for position of teammates and defenders
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Auditory: process instructions from coaches
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Language: communicate with teammates and coaches
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Cognitive: problem solving and implementing sports strategies
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Emotional: possess the ability to process various emotions such as excitement, anxiety, elation of winning, and frustration of losing
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Athletes that are competing in sports at levels above their neurodevelopmental abilities will be more likely to experience negative feelings such as frustration, anger, and lower confidence and self-esteem. Moreover, they will be less likely to have fun and to enjoy the overall sports participation experience. Drop-out as well as injury rates may be higher in these situations.
Psychological Concerns
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Following are the common mistakes made by parents that negatively influence young athletes:
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Choosing sports participation based on what the parent wants and not what the child wants
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Push their children to “over-train”
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Criticize the performance of the young athlete
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Promote a “win-at-all-costs mentality”
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Allow early sports specialization, often in the parent’s sport of choice
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Serve as parent-coaches who either favor or disfavor their own children
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Lack of knowledge about common overuse injuries
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Sports Safety
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Following modifications are appropriate for young, elementary-school-aged participants:
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Use smaller fields and courts and small-sided games (e.g., 6 vs. 6 instead of 11 vs. 11) to encourage participation, activity, and skill acquisition
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Use size- and weight-appropriate equipment
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Shorten duration of games and practice sessions
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Adequate number and length of breaks with opportunities for hydration
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Monitor environmental conditions
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Establish emergency action plans (EAPs) that must be implemented for emergencies related to injury, illness, or environmental conditions
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Additional time during sports participation dedicated for teaching and enforcing rules and safety
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Promote equal playing time and rotate positions
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Avoid score keeping and win–loss records; reinforce “fun” as the goal of sports participation
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