Sports Specialization in Young Athletes

The Committee on Sports Medicine and Fitness of the American Academy of Pediatrics (AAP) has released a statement on the potential risks of intensive training and sports specialization among young athletes. The AAP statement appears in the July 2000 issue of Pediatrics.

According to the AAP committee, children should be encouraged to participate in a variety of different activities and develop a wide range of skills. Increasing numbers of children specialize in a sport at an early age, train all year long and/or compete on an “elite” level. Intense training can lead to short- and long-term health consequences. Physicians who recognize the risks involved can play a key role in monitoring the health of these athletes and help reduce risks associated with high-level sports participation.

The AAP committee makes the following recommendations, keeping in mind (1) the importance of assuring safe and healthy sports play for children, (2) the need to provide practical and realistic guidelines, and (3) the limited research basis for making such recommendations:

• Children should be encouraged to participate in sports at a level consistent with their abilities and interests. Pushing children beyond these limits is discouraged as is specialization in a single sport before adolescence.

• Physicians should work with parents to ensure that the child's coach is knowledgeable about proper training techniques, equipment and the unique physical, physiologic and emotional characteristics of young competitors.

• Physicians and coaches should aim for early recognition and prevention and treatment of overuse injuries. Children should never be encouraged to “work through” such injuries.

• The physician should regularly monitor the condition of child athletes involved in intense training. The physician should focus on serial measurements of body composition, weight and stature; cardiovascular findings; sexual maturation; and evidence of emotional stress. Signs and symptoms of overtraining such as decline in performance, weight loss, anorexia and sleep disturbances should be noted.

• The physician should regularly assess the nutritional intake of the intensely trained child.

• The physician should educate the child, family and coach about the risks of heat injury and strategies for prevention.

ADA Statement on Nutrition in Diabetes

The American Diabetes Association (ADA) has issued a position statement on nutrition recommendations and principles for persons with diabetes mellitus. The position statement is based on current scientific knowledge of nutrition and diabetes. For some recommendations, however, published data are limited. When published data are not available, recommendations are based on clinical experiences and consensus. The ADA position statement appears in a supplement to the January 2000 issue of Diabetes Care.

According to the ADA, medical nutrition therapy is vital to total diabetes care and management. While following nutrition and meal planning principles can be challenging, nutrition therapy is essential to successfully manage diabetes. The overall goal of medical nutrition therapy is to help persons with diabetes make changes in nutrition and exercise habits, which will lead to better metabolic control.

Specific goals of medical nutrition therapy include the following:

• Maintenance of healthy blood glucose levels by balancing food intake with insulin or oral medication and exercise.

• Achievement of optimal serum lipid levels.

• Provision of adequate calories for maintaining reasonable weight for adults, normal rates of growth and development in children, increased metabolic needs during pregnancy and lactation or recovery from catabolic illness.

• Prevention and treatment of the acute complications of insulin-treated diabetes (such as hypoglycemia) and the long-term complications of diabetes (such as renal disease, hypertension and cardiovascular disease).

• Improvement of overall health through optimal nutrition.

The ADA statement discusses the various aspects of nutrition therapy for type 1 diabetes mellitus (formerly known as insulin-dependent diabetes) and type 2 diabetes mellitus (formerly known as non–insulin-dependent diabetes), including the goals of therapy, calorie restriction, meal spacing, exercise, and new behaviors and attitudes. The statement also evaluates the various parts of the daily diet, including protein, total fat, saturated fat and cholesterol, carbohydrate and sweeteners, fiber, sodium and alcohol.

Diagnostic Imaging to Detect Child Abuse

The Section on Radiology of the American Academy of Pediatrics (AAP) has issued a statement on the use of diagnostic imaging in child abuse. Imaging helps physicians to identify the extent of physical injury in an abused child and to elucidate all imaging findings that point to alternative diagnoses. The statement appears in the June 2000 issue of Pediatrics.

According to the AAP committee, the incidence of physical evidence documented by diagnostic imaging studies is relatively low, although these studies are often critical in assessing the infant and young child with evidence of physical injury. They may also be the first indication of abuse in a child who presents with an apparent natural illness. When imaging studies are viewed in conjunction with clinical and laboratory studies, they commonly support allegations of abuse.

According to the AAP committee, physicians should follow the standard skeletal survey developed by the American College of Radiology in all cases of suspected physical abuse in children younger than two years. The committee recommends that these children be evaluated for trauma to the head, spine and abdominal region with the use of such tools as radionuclide bone scan, scintigraphy, magnetic resonance imaging, computed tomography and sonography.

The AAP committee states that thoracoabdominal trauma in abused children should be evaluated and managed in the same way as accidental trauma. Abuse should be suspected when the injury, clinical history or findings on diagnostic imaging studies suggest the possibility of child abuse or nonaccidental injury.

CDC Report on U.S. Incidence of Measles in 1999

According to a report that appears in the June 30, 2000 issue of Morbidity and Mortality Weekly Report (MMWR), measles is no longer endemic in the United States. A total of 100 confirmed cases of measles were reported to the Centers for Disease Control and Prevention (CDC) by state and local health departments during 1999. This total equals the record low number of cases reported in 1998. Since 1997, the incidence of measles has been 0.5 cases or fewer per 1 million persons in the United States.

The MMWR report shows a continuing trend of record low numbers of measles cases and a high percentage of imported cases. In 1999, few cases of measles of unknown source were reported. These cases were not clustered temporally or geographically in patterns that would suggest a chain of endemic transmission. According to virologic data, only imported virus strains were transmitted in the United States in 1999.

In March 2000, the CDC gathered a group of measles experts to evaluate data on the elimination of endemic measles in the United States. The data showed that most states and 99 percent of counties reported no measles cases from 1997 through 1999. Also, measles surveillance was sensitive enough to consistently detect imported cases, isolated cases and small outbreaks.

Evidence of high population immunity included coverage of more than 90 percent with the first dose of measles vaccine in children 19 to 35 months of age since 1996. Among children entering school, coverage was 98 percent. In nearly all states, a second dose of measles vaccine is required for school entry. The MMWR reports that a national sero-survey indicated that 93 percent of persons six years or older have antibody to measles.

Based on these findings, the measles experts concluded that measles is no longer endemic in the United States. However, because this could be reversed if vaccination coverage declines, the CDC recommends that efforts should continue to ensure that the United States maintains high rates of coverage and strong surveillance measures. With the continued threat of imported measles, the experts encouraged strengthened support of global measles control and eradication of the disease.

Managing Pain and Stress in the Neonate

The Committee on Fetus and Newborn and the Committee on Drugs of the American Academy of Pediatrics (AAP), in collaboration with the Fetus and Newborn Committee of the Canadian Paediatric Society (CPS), have issued a statement on the prevention and management of pain and stress in the neonate. The statement appears in the February 2000 issue of Pediatrics.

According to the committees, the objectives of the statement are as follow: to increase awareness that neonates experience pain; to provide a physiologic basis for neonatal pain and stress assessment and management by health care professionals; to make recommendations for reduced exposure of the neonate to noxious stimuli and to minimize associated adverse outcomes; and to recommend effective and safe interventions that relieve pain and stress.

The AAP/CPS committees make the following recommendations for managing pain and stress in the neonate:

• To evaluate and reduce stress and pain in neonates, validated measures and assessment tools must be used consistently and for as long as the neonate requires treatment for stress or pain.

• Health care professionals should use appropriate environmental, behavioral and pharmacologic interventions to prevent, reduce or eliminate stress and pain in neonates.

• Pharmacologic agents with known pharmacokinetic and pharmacodynamic properties and demonstrated efficacy in neonates should be used. Agents that compromise cardiorespiratory function should be administered only by experienced persons in appropriate settings.

• Health care institutions should develop and implement patient care policies to assess, prevent and manage pain in neonates.

• Health care professionals should be educated about assessing and managing stress and pain in neonates.

• Neonatal pain assessment tools that are easily applicable in the clinical setting should be developed.