Wednesday, September 25, 2013

Overuse Injuries in Young Athletes


It stands to reason that young people who play organized sports are going to get injured.

But while young athletes are susceptible to the ankle sprains, wrist fractures and other acute injuries that are common among competitors of all ages, numerous studies indicate that approximately half of the sports-related injuries among children and adolescents in this country are caused by overuse.

These injuries -- pitcher's elbow, swimmer's shoulder, runner's knee, tennis elbow, tendinitis -- are the result of repetitive stress on tendons, bones and joints. Because they develop gradually over time, they are not as obvious as bruises or breaks and can be more difficult to diagnose and treat. But they can also be avoided more easily.

"Overuse injuries in young people are definitely preventable," said Dr. David Martin, an orthopedic surgeon at Wake Forest Baptist Medical Center. "Athletes, especially kids, want to compete and don't necessarily recognize when something's wrong, so we have to be smarter than them."

Involvement in youth sports has boomed over the last 15 years, to the extent that an estimated 30 million children and adolescents in the United States now participate in organized athletic programs. But the incidence of overuse injuries in young athletes has increased at a much quicker rate across all sports, for reasons that are no mystery to sports medicine experts.

"Participation has increased overall and the sports have become more serious, more competitive at an earlier level, so there are many more year-round athletes than there used to be and many more single-sport athletes," said Martin, who is director of sports medicine for Wake Forest University athletics and team physician for the Winston-Salem Dash minor-league baseball team. "Kids playing the same sport year-round have no off-season, and this type of early specialization leads to more stresses and more overuse injuries than you normally would see."

Playing different sports, on the other hand, is good for young people on multiple levels, said Dr. Daryl Rosenbaum, who specializes in family medicine and sports medicine at Wake Forest Baptist.

"You want to develop overall athleticism, even if you hope to excel in one sport, and playing different sports definitely helps with that," said Rosenbaum, who has been a team physician for the U.S. Soccer Federation's under-20 and under-17 men's and women's national teams and served as medical director of this year's Winston-Salem Open tennis tournament. "You also want to avoid an overuse type of injury. It's tough to go pro or be great in your sport if you injure yourself and fall behind everybody else.

"On the mental side of things, there's avoiding burnout," Rosenbaum added. "If someone's pushed too hard too soon at one sport, they may get tired of it and then, if they don't enjoy exercise or sports in the future, that can negatively affect their long-term health."

That view is echoed by Dr. Michael Freehill, a Wake Forest Baptist orthopedic surgeon who specializes in shoulder injuries and assists as team physician for the Winston-Salem Dash.

"Playing multiple sports when you're young, up through high school, is actually beneficial for all your sports," said Freehill, who pitched in the minor leagues for six seasons before attending medical school, reaching the AAA level with two different organizations and making the 40-man roster of the Anaheim (now Los Angeles) Angels. "You're utilizing different muscles and performing different motions, resulting in a better athlete overall.

"Additionally, you're not over-taxing certain areas, such as the elbow or shoulder, as you would by playing the same sport all the time."

Proper rest is also a key factor in minimizing the risk of overuse injuries. The body needs time to recover from strenuous activity, especially when it's a young body with still-growing bones and still-developing muscles and tendons.

For a positive example of recovery time, Freehill points to major-league pitchers, who generally refrain from throwing for three months once the season ends.

"How can anybody argue that time off is not needed?" he said. "These are athletes who perform at the highest level, so it makes no sense to think that children who participate in sports can get by with anything less. The same rules apply to volleyball, swimming, tennis, basketball, all sports."

Rosenbaum recommends that young athletes take at least one day off per week and at least one season off, at least from organized competition in a specific sport, per year. He also emphasizes that both children and adults must realize that "pain is never normal, especially in kids."

"There's no such thing as 'just sore,'" Rosenbaum said. "It's never 'just part of the game.' Nobody, especially a child, should ever push through pain."

It's unlikely that the pursuit of victories, championships, varsity letters, college scholarships and even pro contracts will fade from the youth sports scene anytime soon. But Martin, for one, believes that overuse injuries can be taken out of the picture.

"The key is education," he said. "And it can't be just, 'Well, the doctor says you can only throw so many pitches.' It has to be education for the family, the athletes, the coaches and the people who run the game. Little League baseball is one example -- they've actually changed the game by putting in rules to protect the players' health -- so inroads have been made.

"We also have to educate players, parents and coaches to recognize the signs of overuse, to catch things before they develop into real injury."

Perhaps the most important element, Martin said, is maintaining the proper perspective about sports.

"You have to attach importance to it, but you also have to be sensible," he said. "What I preach is that we have to get everybody involved to think not only about today's game, but about the season, about the player's athletic career, whatever that might be, and about the rest of their life -- especially if the player is 10 years old.

"We're now doing that with concussions. We need to be doing it with overuse injuries, too, and I think that will come."


Monday, September 16, 2013

Soft drinks and behavioral problems in young children



Americans buy more soft drinks per capita than people in any other country. These drinks are consumed by individuals of all ages, including very young children. Although soft drink consumption is associated with aggression, depression, and suicidal thoughts in adolescents, the relationship had not been evaluated in younger children.

A new study scheduled for publication in The Journal of Pediatrics finds that aggression, attention problems, and withdrawal behavior are all associated with soft drink consumption in young children.

Why Kids Should Not be Allowed on Trampolines


Pediatric orthopaedic surgeon says trampolines not worth injury risk


Less than two weeks after getting a new trampoline, 12-year-old Abbey Creamean broke her ankle when she landed awkwardly.

She wore a cast up to her mid-thigh. She had to cancel a dance recital, quit her softball team and give up swimming.


Abbey is among the more than 100 young patients that Dr. Terri Cappello of Loyola University Medical Center has treated during her 15 years as a pediatric orthopaedic surgeon.

“A trampoline puts a child at risk for serious injuries,” Cappello said. “Kids sustain broken arms, legs and even break their necks which can lead to paralysis. Just as you would not let your child jump into a shallow swimming pool, you should not let them jump on a trampoline.”

Cappello agrees with a policy statement from the American Academy of Pediatrics (AAP) that says safety measures such as enclosure nets and padding have not substantially reduced the risk. “Therefore, the home use of trampolines is strongly discouraged,” the Academy statement said.

The AAP estimated that in 2009, there were nearly 98,000 trampoline-related injuries in the United States. And injuries peak during the summer months.

Cappello said trampolines might be worth the risk only when used for training purposes by gymnasts and divers, under careful supervision.

The Pediatric Orthopaedic Society of North America said trampolines and moon bouncers are among the four main areas of preventable injuries in children. (The other areas are skateboards, ATVs and lawnmowers.)

Cappello said injuries typically occur when trampoline users land awkwardly. Common injuries include a broken ankle or a fracture of the tibia (shinbone) just below the knee. Users also can break their necks and become paralyzed.

Abbey was doing a forward flip when her foot grazed the enclosure net. She landed wrong and broke her right ankle.

Abbey had begged for years to get a trampoline. But now her mother says they are getting rid of it, and Abbey isn’t objecting.

“She doesn’t want it anymore,” said her mother, Renee Creamean. “She’s afraid of it now.”




Parents: Do Not Let Your Kids Play Football


Prominent sports medicine physician Dr. Pietro Tonino of Loyola University Medical Center has some blunt advice for parents of high school athletes who want to play football this fall: Don’t let them do it.

“When you have two human beings collide at a high rate of speed – especially if one of them is much bigger than the other – then significant injuries are quite possible,” Tonino said. “I don’t believe it is worth the risk. So I advise parents to try to steer their children to alternative sports. We are just beginning to understand the long-term consequences of injuries sustained at young ages.”

The most common football injuries are knee injuries, especially to the anterior or posterior cruciate ligament (ACL/PCL). Other common injuries are ankle sprains, shoulder injuries and overuse injuries that cause back pain and patellar tendonitis (knee pain). Heat stroke is a significant risk during summer training camp.

A study published in the journal Pediatrics found that injury rates were similar in football and baseball. But while only 3 percent of baseball injuries were considered serious (fracture, dislocation, concussion), 14 percent of football injuries were considered serious.

But concussions are Tonino’s biggest concern. Tonino notes that a position statement from the American Medical Society for Sports Medicine says the developing brain differs physiologically from the adult brain. Young athletes may have a more prolonged recovery and are more susceptible to concussions accompanied by a catastrophic injury.

While helmets can prevent injuries such as cuts and fractures, helmets have not been shown to reduce the incidence and severity of concussions. This is particularly true if improper tackling techniques are used. “Lowering the head and leading with the head can cause serious head and neck injuries, regardless of the quality of the helmet,” Tonino said.

But despite the high injury risk, there generally is inadequate medical supervision during football games and practices. For example, Tonino surveyed football programs in Chicago public high schools and found that only 10.6 percent had a physician on the sideline during games; 8.5 percent had an athletic trainer present; and 89.4 percent had a paramedic available. During practice, no school had a physician or paramedic present, and only one school had an athletic trainer available. The study was published in The Physician and Sports Medicine journal. (Tonino has served as a team doctor for high school, college and NFL football teams.)

Tonino did not let his own two sons play football, but he understands that many other parents will disagree with his advice. In such cases, he advises parents to carefully observe the football program:


•During summer training camp, practices should be held in early morning or early evening, if possible, to reduce the risk of heat injury.


• Keep an eye out for concussions. Does your child suffer from headaches, dizziness or difficulty concentrating?


• Attend a practice. Is there adequate water and ice for players?


• During games, is there a physician or athletic trainer on the sidelines?


• Get to know the coach. During practices, coaches often are the only ones who provide medical supervision.

Young Children Don't Eat Enough Fish


Diets Low in Polyunsaturated Fatty Acids May Be a Problem for Youngsters

In the first study to closely examine the polyunsaturated fatty acid (PUFA) intake among U.S. children under the age of 5, Sarah Keim, PhD, principal investigator in the Center for Biobehavioral Health at The Research Institute at Nationwide Children's Hospital, has found what might be a troubling deficit in the diet of many youngsters. The study, published online today by Maternal and Child Nutrition, used data on nearly 2500 children age 12 to 60 months from the U.S. National Health and Nutrition Examination Survey.

PUFAs are essential to human health. A proper ratio of omega-6 to omega-3 PUFAs plays an important role in cell function, inflammation, eye development and neural functioning. However, the ideal dietary intake of PUFAs for young children is unclear. Knowing that infants often receive significant amounts of key PUFAs through breast milk and infant formula during the first year of life, Dr. Keim and her colleague, Amy Branum, PhD, MSPH, of the Centers for Disease Control and Prevention, decided to estimate the average intake of PUFAs in the diet for children between infancy and kindergarten.

"The ratio of omega-6 to omega-3 intake was high -- about 10. Some experts use this as an indicator of diet quality, with a high ratio being less healthy," says Dr. Keim. "In addition, intake of a key fatty acid known as DHA in children 12 to 60 months of age was low -- lower than what infants generally consume -- and it did not increase with age."

Dr. Keim's study was also the first to examine the primary dietary sources of PUFA intake among children under the age of 5 and to examine age, race and ethnicity in relation to fish intake in this age group. Fish are an excellent source of fatty acids, such as DHA and EPA, and were shown to be the richest sources of PUFAs in children's diets.

"Only about 54 percent of children ate fish at least once in the previous month. Non-Hispanic black children were more likely than non-Hispanic white children to have eaten fish," says Dr. Keim. "Because diet can be an important contributor to many diseases, it's important to understand how such disparities might contribute to disease risk."

The swift physical and neurological development during this period of childhood may mean that variations in PUFA intake could have important implications for growth, she adds.

"This work could help inform dietary recommendations for children, and may be particularly important for the preterm population," Dr. Keim says. "We are currently carrying out a clinical trial to see if DHA supplementation when children are 1 year of age can help cognitive development in those born preterm."

At present, there is no official dietary recommendation in the U.S. for DHA and EPA intake or supplementation among children, although the Institute of Medicine has issued what they call a "reasonable intake" level of two 3-oz servings of fish per week for children. "According to our research, however, children are clearly not consuming this much fish," says Dr. Keim. In addition, the researchers found that overall intake of key fatty acids, such as DHA and EPA, among U.S. children is only a fraction of what is regularly consumed by young children in certain other countries, including Canada. Other studies suggest that similarly low intakes exist in kids age 5 and older. By incorporating key omega-3 PUFAs into a child's diet at a very early age, Dr. Keim says, it may be more likely to become part of a lifelong diet.

Dr. Keim hopes her work will contribute to a more detailed understanding of the diets of young children in the U.S. and will motivate health professionals to start considering the specific nutritional needs of children for healthy growth and development. "We'd like to continue our work examining dietary patterns in very young children, since they are often excluded from dietary studies," she says.

Ideally, Dr. Keim says she would like to see families expose their children to a variety of fresh foods as soon as they are old enough to eat solids. "Dietary habits can form very early, so starting with a balanced diet may have long-lasting effects for children's health." According to Dr. Keim, this balanced diet should include fish and other good sources of healthy fatty acids.

Eating oily fish is also very beneficial to young children


Diet During Pregnancy and Early Life May Affect Children's Behavior and Intelligence

The statement "you are what you eat" is significant for the development of optimum mental performance in children as evidence is accumulating to show that nutrition pre-birth and in early life "programmes" long term health, well being, brain development and mental performance and that certain nutrients are important to this process.

Researchers from the NUTRIMENTHE project have addressed this in a five-year study involving hundreds of European families with young children. Researchers looked at the effect of, B-vitamins, folic acid, breast milk versus formula milk, iron, iodine and omega-3 fatty acids, on the cognitive, emotional and behavioural development of children from before birth to age nine.

The study has found that folic acid, which is recommended in some European countries, to be taken by women during the first three months of pregnancy, can reduce the likelihood of behavioural problems during early childhood. Eating oily fish is also very beneficial, not only for the omega-3 fatty acids they which are 'building blocks' for brain cells, but also for the iodine content which has a positive effect on reading ability in children when measured at age nine.

A long-term study was needed as explained by Professor Cristina Campoy, who led the project "Short term studies seem unable to detect the real influence of nutrition in early life," explained Prof Cristina Campoy, "NUTRIMENTHE was designed to be a long-term study, as the brain takes a long time to mature, and early deficiencies may have far-reaching effects. So, early nutrition is most important."

Many other factors can affect mental performance in children including; the parent's educational level, socio-economic status of the parents, age of the parents and, as discovered by NUTRIMENTHE, the genetic background of the mother and child. This can influence how certain nutrients are processed and transferred during pregnancy and breastfeeding and in turn, affect mental performance.

In giving advice to parents, Cristina Campoy explained, "it is important to try to have good nutrition during pregnancy and in the early life of the child and to include breastfeeding if possible, as such 'good nutrition' can have a positive effect on mental performance later in childhood." She went on to explain, "however, in the case of genetics, future studies should include research on genetic variation in mothers and children so that the optimum advice can be given. This area is relatively new and will be challenging!"

The knowledge obtained by NUTRIMENTHE will contribute to the science base for dietary recommendations for pregnant women and children for improving mental performance.

Low Omega-3 Could Explain Why Some Children Struggle With Reading


An Oxford University study has shown that a representative sample of UK schoolchildren aged seven to nine years had low levels of key Omega-3 fatty acids in their blood. Furthermore, the study found that children's blood levels of the long-chain Omega-3 DHA (the form found in most abundance in the brain) 'significantly predicted' how well they were able to concentrate and learn.

Oxford University researchers explained the findings, recently published in the journal PLOS One, at a conference in London on 4 September.

The study was presented at the conference by co-authors Dr Alex Richardson and Professor Paul Montgomery from Oxford University's Centre for Evidence-Based Intervention in the Department of Social Policy and Intervention. It is one of the first to evaluate blood Omega-3 levels in UK schoolchildren. The long-chain Omega-3 fats (EPA and DHA) found in fish, seafood and some algae, are essential for the brain's structure and function as well as for maintaining a healthy heart and immune system. Parents also reported on their child's diet, revealing to the researchers that almost nine out of ten children in the sample ate fish less than twice a week, and nearly one in ten never ate fish at all. The government's guidelines for a healthy diet recommend at least two portions of fish a week. This is because like vitamins, omega-3 fats have to come from our diets -- and although humans can in theory make some EPA and DHA from shorter-chain omega-3 (found in some vegetable oils), research has shown this conversion is not reliable, particularly for DHA, say the researchers.

Blood samples were taken from 493 schoolchildren, aged between seven and nine years, from 74 mainstream schools in Oxfordshire. All of the children were thought to have below-average reading skills, based on national assessments at the age of seven or their teachers' current judgements. Analyses of their blood samples showed that, on average, just under two per cent of the children's total blood fatty acids were Omega-3 DHA (Docosahexaenoic acid) and 0.5 per cent were Omega-3 EPA (Eicosapentaenoic acid), with a total of 2.45 per cent for these long-chain Omega-3 combined. This is below the minimum of 4 per cent recommended by leading scientists to maintain cardiovascular health in adults, with 8-12 per cent regarded as optimal for a healthy heart, the researchers reported.

Co-author Professor Paul Montgomery said: 'From a sample of nearly 500 schoolchildren, we found that levels of Omega-3 fatty acids in the blood significantly predicted a child's behaviour and ability to learn. Higher levels of Omega-3 in the blood, and DHA in particular, were associated with better reading and memory, as well as with fewer behaviour problems as rated by parents and teachers. These results are particularly noteworthy given that we had a restricted range of scores, especially with respect to blood DHA but also for reading ability, as around two-thirds of these children were still reading below their age-level when we assessed them. Although further research is needed, we think it is likely that these findings could be applied generally to schoolchildren throughout the UK.'

Co-author Dr Alex Richardson added: 'The longer term health implications of such low blood Omega-3 levels in children obviously can't be known. But this study suggests that many, if not most UK children, probably aren't getting enough of the long-chain Omega-3 we all need for a healthy brain, heart and immune system. That gives serious cause for concern because we found that lower blood DHA was linked with poorer behaviour and learning in these children. 'Most of the children we studied had blood levels of long-chain Omega-3 that in adults would indicate a high risk of heart disease. This was consistent with their parents' reports that most of them failed to meet current dietary guidelines for fish and seafood intake. Similarly, few took supplements or foods fortified with these Omega-3.'

The current findings build on earlier work by the same researchers, showing that dietary supplementation with Omega-3 DHA improved both reading progress and behaviour in children from the general school population who were behind on their reading. Their previous research has already shown benefits of supplementation with long-chain omega-3 (EPA+DHA) for children with ADHD, Dyspraxia, Dyslexia, and related conditions. The DHA Oxford Learning and Behaviour (DOLAB) Studies have now extended these findings to children from the general school population.

'Technical advances in recent years have enabled the measurement of individual Omega-3 and other fatty acids from fingerstick blood samples. 'These new techniques have been revolutionary -- because in the past, blood samples from a vein were needed for assessing fatty acids, and that has seriously restricted research into the blood Omega-3 status of healthy UK children until now,' said Dr Richardson.

The authors believe these findings may be relevant to the general UK population, as the spread of scores in this sample was within the normal population range for both reading and behaviour. However, they caution that these findings may not apply to more ethnically diverse populations as some genetic differences can affect how Omega-3 fatty acids are metabolised. Most of the children participating in this study were white British.