Should your child have an Athletic Heart Screen?

In recent years I’ve been getting more and more reports of athletic heart screenings. Local schools and sports clubs are offering to have athletes get a heart work up for a relatively small fee. Of course most are perfectly normal, which is a peace of mind to parents. Some have found minor things that aren’t of much consequence, but a few have found important heart issues. So why is there even a question of whether or not to do an athletic heart screen if it discovers important heart issues?

Why worry about healthy athlete hearts?

Sudden cardiac death in athletes has been in the news a lot over the years. We all want to minimize the risk that our child has an undiagnosed heart condition that may cause sudden death when exercising. We want to prevent sudden death by identifying those at risk and keeping them from the activities that increase risk.

Communities and schools now are more likely to have defibrillators on hand in case of problems, but some children might benefit from an implantable defibrillator.

If you’ve not taken a CPR class in the past few years, a lot has changed, including teaching people how to use defibrillators. And you no longer follow “A B C” so it is very different. CPR is recommended for all teens and adults.

Is the cost of a heart screen worth it?

Assessment of the 12-Lead ECG as a Screening Test for Detection of Cardiovascular Disease in Healthy General Populations of Young People (12–25 Years of Age): A Scientific Statement From the American Heart Association and the American College of Cardiology is a review of whether or not electrocardiograms (ECGs) are beneficial for all athletes prior to sport participation. It is endorsed by the Pediatric and Congenital Electrophysiology Society and American College of Sports Medicine.

There has been a lot of controversy over the years whether or not routine ECG screening of athletes is a cost-effective means to find at risk young people. Northeastern Italy has done a comprehensive screening program of competitive athletes and has lowered their sudden cardiac death rate, which is evidence for the ECG screening. Despite this shown benefit, there are many problems with the feasibility of testing a broad range of athletes to evaluate for risk of sudden death (SD).

Complex issues from the Statement linked above:
  1. the low prevalence of cardiovascular diseases responsible for SD in the young population
  2. the low risk of SD among those with these diseases
  3. the large sizes of the populations proposed for screening
  4. the imperfection of the 12-lead ECG as a diagnostic test in this venue

It is generally agreed upon that screening to detect cardiovascular abnormalities in otherwise healthy young competitive athletes is justifiable in principle on ethical, legal, and medical grounds. Reliable exclusion of cardiovascular disease by such screening may provide reassurance to athletes and their families.

In short: 

To do an ECG screening on all athletes is not inherently unwarranted nor discouraged, but it isn’t recommended either.

What is recommended?

Although an ECG is not recommended, it is recommended to do a 14 point questionnaire for all athletes at their pre-participation sports exam. This is listed below.

Why isn’t an ECG (commonly called EKG) recommended?

Positive findings on the history (questionnaire) or physical exam may require further testing, but using an ECG as the initial screen for underlying problems in the 12- to 25-year age group hasn’t been found to save lives.

Changes in the heart in growing teenagers can make it difficult to tell if an ECG is abnormal or a variation for age (unless read by a pediatric cardiologist, which is often not possible for these mass screenings).

False negative and positive results can lead to missed diagnoses (normal ECG but real underlying condition) or unneeded testing (abnormal ECG with a normal heart).

Mass ECG screening of athletes would be very expensive and has not been proven to save lives.

If your family can bear the cost and wants to do the screening, it should be done. But if the screen is abnormal, do not jump to the conclusion that your athlete will be banned from sports forever. A more complete exam by a pediatric cardiologist will sort that out.

Know that hearts can change over time. One normal screen does not guarantee there will never be a cardiac event in your child.

If you do not feel that the screening is something you want to pay for or if you feel that it is not necessary for your child who has a negative 14 point screening, you should not be required to do so.

The evidence does not support mass required screenings.

If your child has identified risks based on the questionnaire, a more thorough testing should be done.

What are the 14 points?

These 14 points are listed in Table 1 of the above linked statement: The 14-Element AHA Recommendations for Preparticipation Cardiovascular Screening of Competitive Athletes

Medical history*
Personal history 

1. Chest pain/discomfort/tightness/pressure related to exertion
2. Unexplained syncope/near-syncope†
3. Excessive and unexplained dyspnea/fatigue or palpitations, associated with exercise
4. Prior recognition of a heart murmur
5. Elevated systemic blood pressure
6. Prior restriction from participation in sports
7. Prior testing for the heart, ordered by a physician

Family history

8. Premature death (sudden and unexpected, or otherwise) before 50 y
of age attributable to heart disease in ≥1 relative
9. Disability from heart disease in close relative <50 y of age
10. Hypertrophic or dilated cardiomyopathy, long-QT syndrome, or other ion channelopathies, Marfan syndrome, or clinically significant arrhythmias; specific knowledge of genetic cardiac conditions in family members

Physical examination

11. Heart murmur‡
12. Femoral pulses to exclude aortic coarctation
13. Physical stigmata of Marfan syndrome
14. Brachial artery blood pressure (sitting position)§

  • AHA indicates American Heart Association.
  • *Parental verification is recommended for high school and middle school athletes.
  • †Judged not to be of neurocardiogenic (vasovagal) origin; of particular concern when occurring during or after physical exertion.
  • ‡Refers to heart murmurs judged likely to be organic and unlikely to be innocent; auscultation should be performed with the patient in both the supine and standing positions (or with Valsalva maneuver), specifically to identify murmurs of dynamic left ventricular outflow tract obstruction.
  • §Preferably taken in both arms.

What do I recommend?

I think that if you can afford the screen and any potential follow up recommended if it is abnormal, it is a great tool. It can be reassuring, though nothing can guarantee that no problem will develop.

In a perfect world cost wouldn’t matter, but I know it does, so if people can’t afford the screening, they should not feel like they are not doing the right thing if they skip it.

The 14 point question is all that is recommended to be done and can catch the majority of problems if done with a thorough physical exam.

A plug for an annual well visit in your medical home.

I think all kids and teens should have annual physicals in their medical home. The medical home is where their primary care physician is.

I know this is difficult due to the requirement of all athletes have a physical in a specified time frame before a season starts, but there are benefits to doing a physical in the medical home. At your usual physician’s office there should be record of growth over the years, a complete personal and family medical history, and previous vital sign measurements. Not to mention that your regular clinic should be able to update your vaccines if needed so there are no surprises when your school nurse looks at your record in the fall. Seeing your physician yearly also helps to build a relationship, so there is a better comfort level to talk if problems develop.

At this time insurance generally covers one well visit per year. Most physicians will fill out the sports physical form at this annual visit. When you go elsewhere, you usually must pay cash. You might as well get a comprehensive physical using your insurance. You pay a monthly fee for the privilege of having it – use it! Just be sure to schedule well in advance – everyone needs physicals at the same time due to state or club requirements, so slots fill up quickly.

Schedule your physical when you schedule a sport or camp.

When you sign your kids up for any new school, sport or camp, look to see what forms are needed. Call your doctor’s office at the same time you sign up for the sport or camp to schedule the annual physical. Just be sure the date you schedule is in the time frame that is needed  to get the forms completed.

Pay attention to your insurance rules for how often physicals can be done. Don’t necessarily schedule near your child’s birthday if it is outside the range that is needed to fulfill form requirements so you can avoid a second physical when only one per year is allowed.

If in doubt, call your pediatrician’s office and ask!

Should your child have an Athletic Heart Screen?
Should your child have an Athletic Heart Screen?

Kids to Parks Day

Each year Kids to Parks Day is celebrated on the 3rd Saturday of May. It’s a day we can help kids and families connect with their local, state, and national parks and have fun! This year it’s Saturday, May 19th.

Why should we have a national day to celebrate taking kids to a park?

Because anything that encourages families and friends to explore the outdoors together is a great thing!

Where should you go?

If you’re wondering where to go, check out this great page from the National Park Trust called Explore Parks Near You. You can click on the state you want to explore to find parks.

Of course if there’s no national park near you, you can visit any nearby park or trail. The point is to get outside and enjoy nature.

What can you do?

Parks may offer a number of activities. You can investigate if they have hiking or biking trails, water activities such as swimming or fishing, camping, or more.

Check out these Boredom Busters and the ideas in this Park Adventure Booklet for your next park trip. You can also try to do all thirty of these 30 Things. If your kids are into creative games, you can have them go on a scavenger hunt.

What should you bring?

Always make sure you’re prepared when you’re going into nature.

Sunscreen and sun protection from hats and clothing is a must when outdoors. Use at least an SPF of 25 and reapply sunscreen every 2 hours until evening hours.

Sunglasses might also be appreciated and help protect the eyes from damaging rays. Be sure your sunglasses provide 100% UV protection from both UVA and UVB rays. Don’t forget the kids! We get 75-80% of our UV exposure before we turn 18.

Use bug sprays and sunscreens appropriately. Don't buy a combination product. Use the sunscreen first, and then spray bug spray over it if needed.
Use bug sprays and sunscreens appropriately. Don’t buy a combination product. Use the sunscreen first, and then spray bug spray over it if needed.

Bug sprays can help prevent bug bites. If you’re in an area with ticks, still do daily tick checks even if you use insect repellant. You can use this handy online tool to find the best bug spray for your needs.

Be sure to bring water bottles for everyone. Dehydration is a risk when you’re active, especially if it’s warm outside. Caffeinated (and for adults, alcoholic) beverages don’t rehydrate as well as water.

Wear appropriate shoes. Many kids want to wear their favorite sandals, but if you’ll be outdoors walking, they will need a more sturdy shoe. If you’ll be around water you might even pack a second pair in case they get wet. Walking in wet shoes is begging for blisters.

Bring a camera to take memories, but don’t spend the day trying to get the perfect picture. Snap a few pictures, but make the day about enjoying the outdoors, not about taking pictures.

If you’ll be hiking, bird watching, or looking for wildlife, it might be helpful to have binoculars.

Bring healthy snacks or pack a lunch if you’ll be out during typical snack or meal times. When kids are hungry, they get angry. You don’t want hanger to ruin a fun day!

If there are areas appropriate for sporty activities, bring some balls or frisbees.

What should you not bring?

Leave the electronics at home. This is a great day to unplug!

If you have allergies in the family…

If someone (or many) in your family suffer from allergies, be prepared! I have many tips in a previous blog that covers allergies.

#KidstoParks

Get your kids outdoors on Kids to Park Day!
Get out and into nature!

Is Sport Specialization A Good Idea?

I’ve seen many young athletes have their athletic careers cut short due to preventable injuries and / or burnout. We live in a competitive time and everyone likes to feel successful. When kids do well in a sport, we want to encourage them to be their best, so we let them try out for the competitive team and even play on several teams throughout the year. While this can seem to help them improve their skills and grow to be a better player, it often has the opposite effects.

sportsThe American Orthopaedic Society for Sports Medicine has released a Consensus Statement on this topic. Many parts echo the consensus statement of the American Medical Society for Sports Medicine.

A consensus statement is basically a summary of what leading experts believe based on current research and understanding.

If you don’t want to read the entire summary below, just know that experts aren’t in favor of it.

They do acknowledge that there are a few sports- such as gymnastics, figure skating, swimming and dance- that might benefit from earlier specialization because their peak years are in the teens and twenties.

Current research shows that before puberty children should be encouraged to participate in a variety of sports that match their level of ability.

They should also be allowed free play that does not have direct coaching from adults.

Playing various sports helps to develop muscle strength and skills that can be protective of injury. Playing various sports and including unstructured playtime helps develop not only sports-related skills, but also helps them develop psychologically and socially.

What do the consensus statements say?

They start by defining early sport specialization as the following:

  • Participation in organized sports more than 8 months per year
  • Participation in one sport rather than several different sports
  • Children before the pubertal years, which they state is roughly 7th grade or 12 years, but ranges considerably and is typically 8-13 years in girls and 10-15 years in boys


Risks of early sport specialization include:

  • Over scheduling
  • Burnout
  • Overuse injuries
Over scheduling risks

Over scheduling can lead to increased stress and anxiety and overall poor habits.

It can decrease the amount of time a student can study. Obviously children need to have time to study so they can learn the most they can in school to prepare them for life.

Organized sports do not allow children to interact in an unstructured way with other kids. The time lost in free play can set kids behind peers in social skills.

Being over scheduled often results in sleep loss, which can contribute to mood and behavior changes as well as poor growth.

As families run from activity to activity, they often miss out on family meals. Family meals are important for family bonding and are associated with healthier eating.

When families run through a drive thru or get pizza between practices and games, they are foregoing a healthy balance of lean proteins, fruits, and vegetables.

Burnout

When kids live a sport day in and day out they are at risk of burnout.

A child who once loved soccer or baseball might one day decide they want to quit the sport all together if they don’t have balance in life.

They often plateau or decline in sport performance. This might be a part of a larger depression or anxiety, or simply a desire to scale back or to try something new.

Signs of burnout include moodiness, irritability, trouble focusing, appetite loss, headaches, stomach aches, decreased strength and coordination, and increased rates of illness.

Overuse injuries

Overuse injuries are common when kids do the same activity over and over, day after day without time for adequate rest between activities.

Prevention can include taking proper time to rest, slowing increasing intensity, strength training and rotating types of activity throughout the year.

Some suggestions made in the consensus statements listed above to avoid injuries and burnout include:

  • Rest at least 1 day each week
  • Take at least 3 months off each year (1 month every 3 months)
  • Increase intensity only 10% each week
  • Limit sport-specific repetitive movements (such as pitching)
  • Play on only one team per season
  • Use conditioning programs to strengthen supporting muscles
  • Learn and use proper techniques
  • Keep play fun
  • Play no more hours per week than age (i.e. 12 hours / week maximum for a 12 year old)
  • Insure proper sleep for age
  • Maintain a healthy diet
  • Wear proper sport – specific protective gear that is the right size and in good condition

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Weight is Weighing on My Mind

Too much sugar is causing an epidemic of obesity in our kids. Even the ones who aren’t overweight are often less healthy due to food choices. Excess sugar consumption over time is linked to many health issues such as high cholesterol, diabetes, metabolic syndrome, and it can trigger earlier puberty – leading to overall shorter adult height. Not to mention the psychological and social implications of bullying, depression, eating disorders, and more.

Back in the day…

Why is weight so much more of a problem now than it was years ago?

As a child I did not have a perfect diet, yet I was not overweight (and neither were my classmates) because we spent most waking moments outside if we weren’t in school.

My mother packed a dessert in every lunch box. We ate red meat most days. My mother usually put white bread and butter on the table at dinner. I drank 2% milk and ate ice cream every night.

But we walked to school– without a parent by the time I was in 1st grade. (gasp!)

There were only a couple tv channels, and Saturday morning was the only time we could watch tv.

We were able to ride bikes, go to a wooded area, play on a nearby playground, dig in the dirt, you name it – we found something to make it fun!

Update: I just read a fantastic blog from Dr. Alison Escalante that shows beautifully how she and her siblings were able to explore and learn as kids. Take a look at The Summer of No TV: Why Boredom Breeds Creativity Part 1.

Why is weight so much more of a problem now than it was years ago?
unhealthy foods
Childhood obesity is a growing problem. Kids need to eat healthy and move daily.

I think it’s a combination of what they’re eating and what they’re doing.

Today’s kids are shut up in the house after school watching one of many tv channels or playing video games.

Even those who are shuttled to activities get overall less exercise because it is structured differently than free play. They ride in the car to practice or class, then sit and wait for things to start. They might sit or stand while others are getting instruction.

Simply put: They eat a lot of processed and junk food and they don’t get to do active things at their own pace with their own creativity for as long as they want.

Shouldn’t we worry about them getting hurt?

I know parents are worried that their kids will get hurt or abducted if they play outside with friends, especially if they go out of sight from a parent. But I think in some ways we’re killing our kids slowly by allowing unhealthy habits to kick in.

The reality is that most kids won’t get hurt if they’re playing. Yes, some will. But if they play video games all day, they won’t get injured. They are likely to have long term problems though.

I’m seeing adult problems in young kids, such as Type 2 diabetes, high cholesterol, non-alcoholic fatty liver disease, hip/knee problems, and more. The poor kids who are overweight have the potential to suffer long term consequences.

What to do???

On one hand kids need to learn to make healthy choices to maintain a healthy body weight for height, but on the other hand you don’t want to focus so much on weight that they develop eating disorders. I think this is possible if we focus on the word “healthy” – not “weight”.

Starting at school age I ask kids at well visits if they think they are too heavy, too skinny, too short, or too tall. If they have a concern, I follow up with something along the line of, “How would you change that?” I’m often surprised by the answers, but I can use this very important information to guide how I approach their weight, height, and BMI. We talk about where they are on the graph, and healthy ways to either stay in a good place or how to get to a better BMI.

I focus on 3 things we all need to be healthy (not healthy weight, but healthy):

  1. Healthy eating (eat a plant and protein each meal and snack)
  2. Exercise (with proper safety equipment but that’s another topic!)
  3. Sleep (again, another topic entirely!)
Food is a part of our daily needs, but much more than that.

It’s a huge part of our lifestyle.

We have special meals for celebrations but on a day to day basis it tends to be more repetitive.

We all get into ruts of what our kids will eat, so that is what we prepare. The typical kid likes pizza, nuggets, fries, PB&J, burgers, mac and cheese, and a few other select meals.

If we’re lucky our kids like one or two vegetables and some fruits. We might even be able to sneak a whole grain bread in the mix.

If our family is busy we eat on the run– often prepared foods that are low in nutrition, high in fat and added sugars, and things our kids think taste good (ie things we won’t hear whining about).

We want our kids to be happy and we don’t want to hear they are hungry 30 minutes after the meal is over because they didn’t like what was served and chose not to eat, so we tend to cave in and give them what they want.

We as parents need to learn to stop trying to make our kids happy for the moment, but healthy for a lifetime.

There’s often a discrepancy between the child’s BMI (body mass index) and the parent’s perception of healthy.

The perception of calorie needs and actual calorie needs can be very mismatched. I have seen a number of parents who worry that their toddler or child won’t eat, so they encourage unhealthy eating unintentionally in a variety of ways:

  • turn on the tv and feed the child while the child is distracted
  • reward eating with dessert
  • refuse to let the child leave the table until the plate is empty
  • allow excessive milk “since at least it’s healthy”
  • allow snacking throughout the day
  • legitimize that a “healthy” snack of goldfish is better than cookies
Any of these are problematic on several levels.  Kids don’t learn to respond to their own hunger cues if they are forced to eat.  
If offered a choice between a favorite low-nutrition/high fat food and a healthy meal that includes a vegetable, lean protein, whole grain, and low fat milk, which do you think any self-respecting kid would choose?
If they’re only offered the healthy meal or no food at all, most kids will eventually eat because they’re hungry.
No kid will starve to death after 1-2 days of not eating.  
They can, however, over time slowly kill themselves with unhealthy habits.  

So what does your child need to eat?

Think of the calories used in your child’s life and how many they really need.  Calorie needs are based on age, weight, activity level, growing patterns, and more.
It’s too hard to count calories for most of us though.
If kids fill up on healthy options, they won’t be hungry for the junk.
Offer a plant and a protein for each meal and snack. Plants are fruits and vegetables. Proteins are in meats, nuts, eggs and dairy.
Don’t think that your child needs to eat outside of regular meal and snack times.
One of my personal pet peeves is the practice of giving treats during and after athletic games. It’s not uncommon for kids to get a treat at half time and after every game. Most teams have a schedule of which parent will bring treats for after the game.
Do parents realize how damaging this can be?  
  • A 50 pound child playing 15 minutes of basketball burns 39 calories.  Think about how many minutes your child actually plays in a game. Most do not play a full hour, which would burn 158 calories in that 50 pound child.
  • A 50 pound child burns 23 calories playing 15 minutes of t-ball, softball, or baseball.  They burn 90 calories in an hour.
  • A non-competitive 50 pound soccer player burns 34 calories in 15 min/135 per hour. A competitive player burns 51 calories in 15 min/ 203 in an hour.
  • Find your own child’s calories burned (must be at least 50 pounds) at CalorieLab.
Now consider those famous treats at games.
Many teams have a half time snack AND an after game treat.  Calories found on brand company websites or NutritionData:
  • Typical flavored drinks or juice range 50-90 calories per 6 ounce serving.
  • Potato chips (1 ounce) 158 calories (A common bag size is 2 oz… which is 316 calories and has 1/3 of the child’s DAILY recommended fat intake!)
  • Fruit roll up (28g) 104 calories
  • 1 medium chocolate chip cookie: 48 calories
  • Orange slices (1 cup): 85 calories
  • Grapes (1 cup): 62 calories
  • Apple slices (1 cup): 65 calories

So…Let’s say the kids get orange slices (a lot of calories but also good vitamin C, low in fat, and high in fiber) at half time, then a fruit drink and cookie after the game. That totals about 200 calories.

The typical 50 pound soccer player burned 135 calories in a one hour game. They took in more calories than they used.

They did get some nutrition out of the orange, but they also ate the cookie and fruit drink.

The cookie has fewer calories than other options but no nutritional value and a lot of added sugars.

The kids end up taking in many more calories than they consumed during play.

Water

What’s wrong with WATER? That’s what we should give kids to drink at games.

They should eat real food after the game if only they’re hungry.  Snacks are likely to decrease appetite for the next meal, so if they’re hungry give a mini-meal, not a sugar-filled, empty calorie treat every game.

There are many resources on the web to learn about healthy foods for both kids and parents. Rethink the way you look at how your family eats.

Simple suggestions:

      • Offer a fruit and vegetable with a protein at every meal and snack. Fill the plate with various colors! (As I tell the kids: eat a plant and a protein every time you eat ~ meals and snacks!)
      • Picky kids? Hide the vegetable in sauces, offer dips of yogurt or cheese, let kids eat in fun new ways – like with a toothpick. Don’t forget to lead by example and eat your veggies!
      • Buy whole grains.
      • Choose lean proteins.
      • Don’t skip meals.
      • Make time for sleep.
      • Get at least 60 minutes of exercise a day!
      • Eat together as a family as often as possible.
      • Turn off the tv during meals. Don’t use distracted eating!
      • Encourage the “taste a bite without a fight” rule for kids over 3 years. But don’t force more than one bite.
      • Don’t buy foods and drinks with a lot of empty calories. Save them for special treats. If they aren’t in the home, they can’t be eaten!
      • Drink water instead of juice, flavored drinks, or sodas.
      • Limit portions on the plate to fist sized. Keep the serving platters off the table.
      • Eat small healthy snacks between meals. Think of fruit, vegetable slices, cheese, and nuts for snacks. I tell kids all the time: eat a plant and a protein every time you eat – both meals and snacks. Think of snacks as mini-meals!

 

 

Lead by Example

We’ve all heard the saying: kids will do what they’re shown, not as they’re told. Lead by example.

It’s so true. Think about all the times your kids are watching you. They are learning from you.

What can you do to help them have healthy habits?
  • Eat your vegetables.
  • Get daily exercise.
  • Wear your seatbelt.
  • Stop at stop signs.
  • Don’t use your phone while driving.
  • Wear a life vest near a lake or river.
  • Maintain your composure during times of stress.
  • No phones at the dinner table.
  • Don’t tell lies- even little ones.
  • Get enough sleep.
  • Be kind to others.
  • Call home- your parents and siblings would love to hear from you.
  • Don’t permit violence in your presence.
  • Give your time and talents to others.
  • Take care of your things.
  • Limit screen time.
  • Brush your teeth at least twice a day and floss daily.
  • Wear a helmet when on a bike.
  • Don’t mow the lawn without proper shoes.
  • Make time for family.
  • Lead by example every day!

 

helmets, exercise
Exercising together safely as a family sets great lifelong habits!