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• W4206119364 abstract "After reading this article, readers shouldRegular appropriate exercise and other physical activity can provide numerous psychological and social advantages, as well as improvements in overall health and fitness for school-age youth. (1) Participation in youth sports and associated training and practice also can be an effective way for youth to engage in physical activity that will help them to achieve and maintain beneficial gains in body composition, musculoskeletal and cardiovascular health, and overall fitness. (2,3) The benefits of regular physical activity and sports participation as a student athlete can extend even to enhanced academic achievement. (4,5,6)Training or conditioning for or playing sports effectively and safely in the heat, however, can be particularly challenging, especially during “2-a-days” or organized tournament competition, when young athletes have to train or compete in demanding environmental conditions multiple times on the same day. (7) Until recently, there had been very few sport- or physical activity–specific studies on hydration and thermoregulatory challenges and responses in natural outdoor settings with active youth; accordingly, most hot weather recommendations and guidelines for effectively managing hydration, reducing thermal strain, optimizing performance, and minimizing exertional heat illness risk are not amply evidence based or sport specific. (8)Recent research, however, has provided new insights into the physiologic responses and tolerance of young athletes during exercise and sports in the heat, as well as the risk for significant accumulated body water deficits and thermal strain that can affect perception of effort, performance, and safety. In particular, there has been a long-standing perspective that children are less effective than adults in regulating body temperature during exercise in the heat and consequently are less tolerant of and capable of performing well in a hot environment. Accordingly, the concern has been that youth are at greater risk for incurring exertional heat illness compared with adults. However, more current research does not support this viewpoint, indicating that children (9 to 12 years old) do not have insufficient cardiovascular capacity, less effective thermoregulation, or lower exercise-heat tolerance when hydration is maintained sufficiently. (9,10,11,12)Thus, appropriate and effective safety and performance guidelines for youth athletes training and competing in the heat should focus on readily modifiable risk factors, such as intensity and duration of activity, hydration management, and scheduling of play versus any purported inherent thermoregulatory disadvantages. The information presented here addressing this perspective can help pediatricians and other health-care clinicians, parents, coaches, and youth sports governing bodies to improve the health and safety of youth athletes during practice, training, and competition in the heat so that they can continue to participate, have fun, and enjoy the health-enhancing benefits of sports.As environmental heat stress (air temperature, humidity, and solar radiation) and intensity and duration of practice, training, or play increase, the need for evaporative cooling and sweating increases proportionately, and the risk for incurring a measurable body water deficit is augmented. Myriad adolescent athletes are capable of sweating rates in excess of 1.0 L/h during practice, training, and tournament competition in the heat. (13) In older adolescents, sweating rates often can reach 2.5 L/h or more with strenuous physical activity in hot and humid weather. (14) Reports on sweat losses in younger athletes during sports practice, training, or competition are limited; however, sweat loss rates in 9- to 12-year-old boys and girls have been reported to be 300 to 700 mL/h during nonsport exercise in the heat. (9,10,12,15,16)Considering these sweat rates, it is easy to appreciate how a young athlete can readily incur a significant total body water deficit during practice, training, and competition, especially when participating in multiple sessions on the same day over several days in a row. Even when a young athlete voluntarily drinks regularly in response to thirst during activity, a postexercise body water deficit often is significant following a long practice, training session, or contest. This deficit can potentially have a measurable effect on subsequent cardiovascular and thermal strain, as well as exercise-heat tolerance, performance, and safety, to the detriment of the athlete.Accordingly, effective strategies to encourage sufficient fluid intake and optimize hydration status can play an important role in maintaining performance and reducing the risk of exertional heat illness. Generally, 100 to 250 mL (∼3-8 oz) every 20 minutes for 9- to 12-year-olds and up to 1.0 to 1.5 L (∼34-50 oz) per hour for adolescent boys and girls is enough to minimize sweating-induced body water deficits sufficiently during exercise and other physical activity, as long as preactivity hydration status is good.Notably, the effects of poor or casual hydration habits of young athletes developed during practice often are magnified by the more extensive sweat losses and repeated recovery demands of competitive tournament play. Therefore, it may be helpful for young players (and their parents and coaches) to emphasize beginning all practice sessions in a well-hydrated state, consuming fluids regularly (eg, every 10 to 15 minutes), and deliberately beginning rehydration promptly after practice to recover any remaining body water deficit. The goal would be to promote better hydration behavior that, it is hoped, would carry over to and minimize body water deficits during competition.Minimizing voluntary dehydration in young boys has been more effective during exercise in the heat when a more preferred (compared with flavored or unflavored water) carbohydrate-electrolyte drink was available. (17,18) However, more recently, unflavored water has been shown to be equally effective as a carbohydrate-electrolyte sports drink in maintaining body weight in physically active young girls during intermittent exercise in the heat. (19) These conflicting findings may be related to sex, fitness, or athletic experience.In high-level, fit junior tennis players, Bergeron et al (13) observed only a small difference in ad libitum fluid consumption between water and a commercial sport drink during intense on-court training in the heat. This behavior may reflect a more disciplined fluid consumption behavior characteristic of experienced competitive tennis players and other well-informed skilled competitors. That is, elite young athletes are encouraged regularly to rehydrate sufficiently and may be more likely to maintain a consistent fluid intake rate during training and competition regardless of beverage flavoring and appeal. In contrast, in nonathletic children, the flavoring of a sports drink may prompt more measurable differences in fluid intake volume.Optimal rehydration, during and after extensive physical activity, often involves more than simply ample fluid intake. With growth and maturation, a young athlete’s sweat rate increases through the adolescent years. Concomitantly, sweat electrolyte losses (particularly of sodium and chloride) during sports practice, training, and play generally increase as well, due to a larger volume of sweat and a greater sweat sodium concentration. Acclimatization to the heat typically lowers one’s sweat sodium concentration; however, sweat sodium losses still can be substantial, even for a young athlete who is well acclimatized to the heat.With pre- or early pubescent athletes, the potential sweat-induced sodium deficit incurred during a single practice or training session or game/match is not likely to have a significant physiologic or performance impact. A normal diet typically will be sufficient to maintain daily electrolyte balance, even if only water is consumed while on-court or on the field. This situation often is not the case with older adolescents, who generally sweat considerably more and can lose 2000 to nearly 5000 mg/h of sodium via sweating. (14,20)Therefore, to offset these greater electrolyte losses and to better retain and distribute the large volume of ingested water to all body fluid compartments, (21,22,23,24) a more deliberate effort to match sodium intake during and between each session or event with individual sweat sodium losses is imperative; otherwise, insufficient sodium intake will hinder complete rehydration, may affect physiologic function and performance, and can increase the risk of incurring exertional heat cramps. (25)Although recent research with 9- to 12-year-olds indicates that youth are at no greater risk for incurring exertional heat illness compared with adults, cardiovascular and thermoregulatory capacity and exercise-heat tolerance certainly can be strained during youth sports in the heat. Even with adequate hydration, a child’s metabolic heat production, heat storage, and thus body core temperature will progressively and rapidly increase during long-term and high-intensity physical activity, respectively, in the heat.Repeated complex, intermittent exercise patterns with varying workload and recovery periods (characteristic of many competitive youth sports) has been shown to induce greater physiologic strain and yield higher heat storage and body core temperature compared with continuous exercise, (26) suggesting a particularly great clinical risk during certain sports (eg, soccer, singles tennis, or football conditioning drills) when there is a long period of recurring high-intensity activity in the heat.Fortunately, to date there have been very few reported exertional heat stroke deaths in most youth sports held outdoors, with the stark exception of American football, in which 40 high school football players have died from exertional heatstroke (EHS) between 1995 and 2010. (27) At the same time, extensive thermal strain is observed routinely in young athletes in a variety of sports during hot-weather training and competition. Accordingly, the Centers for Disease Control and Prevention examination of the incidence and characteristics of exertional heat illness among high school athletes and those treated in emergency departments more closely underscores the true extent of this problem, as well as the predominant frequency and severity associated with football. (28,29) Unfortunately, however, the prevalence and extent of significant body core temperature responses that do not result in emergency department treatments and specific sport-, activity-, and environment-related exertional heat illness risks are largely unknown in youth sports.Much of the limited thermal strain assessment in youth sports has been conducted in tennis. Bergeron et al (13) indicated that a carbohydrate-electrolyte drink may have been more effective than water in maintaining hydration status and minimizing thermal strain in highly skilled, fit junior tennis players during intense on-court training in a very warm environment. Although a number of players began the monitored training sessions not well hydrated, as indicated by prepractice urine specific gravity, these young athletes generally incurred a sweat-induced body weight deficit of only less than 1% of initial body weight.This effect may have been facilitated by the regular (ie, every 10 minutes) 3-minute breaks implemented for rest, instructions/coaching, and rehydration from large prepared individual coolers containing chilled beverage. Without these frequent opportunities to drink and ample beverage availability, these young players might not have been so attentive to regular and sufficient fluid intake. That is, these same young athletes on their own might have been expected to incur significantly greater body water deficits than observed in this study.Unlike tournament competition, even well-supervised practice permits individuals to vary their own intensity and effort, without being “penalized” (affected) as severely for insufficient fluid intake, even though body core temperature responses approached or reached 39°C for some players during the 2-hour practice sessions. This behavior does not, however, reinforce good hydration habits for sanctioned hot-weather tournament events, in which there is a smaller margin of error and in which a significant total body water deficit is more likely to be reflected in greater thermal strain and lower on-court performance.Bergeron et al (30) also studied 8 elite-level, early-adolescent boys during the first round of singles and doubles play in a national championships event during the first week in August in San Antonio, Texas. These monitored singles matches were contested mostly in the morning; so environmental conditions were not particularly challenging. Of note, preplay hydration status (indicated by urine specific gravity) was associated with on-court thermal strain, and this relationship was stronger as the matches advanced. That is, those players who began the match not well hydrated were more likely to incur a high body core temperature as play continued because the measured on-court core temperature responses exceeded 39°C for some players.Because this was a national tournament, players maintained a strong effort; thus, it was not surprising to see greater thermal strain in those players starting off their matches with an apparent greater body water deficit. In fact, had the players been monitored during longer, more intense, 3-set matches played in the afternoon during later rounds of the tournament, the author speculated that on-court thermal strain would have been consistently even higher than observed during the less challenging opening matches of the first round of play because of greater heat stress, intensity and duration of play, and potential body water deficits incurred. This study also highlighted how even doubles play in junior tournament-level tennis can elicit appreciable metabolic heat production and storage.Fairly high levels of thermal strain also have been demonstrated during high school preseason football practice sessions, even when environmental conditions were not very stressful, when the coaches progressively phased in the wearing of protective equipment and of the full uniform, and when only one practice session was held per day. (31) This observation underscores the critical importance of providing an appropriate acclimatization period at the beginning of preseason practice outdoors in the heat, especially in youth football.One of the biggest challenges for a youth athlete in the maintenance of hydration (sufficient water and electrolyte balance and distribution to all fluid compartments), minimizing of thermal strain, and achievement of optimal performance is hot-weather tournament play, when multiple matches/games are scheduled on the same day with inappropriately short rest and recovery periods between contests. (7) This packed schedule is a common scenario in youth sports tournaments, especially at the state- and regional-level events. Not all tournament administrators and youth sports governing bodies’ guidelines for minimum rest periods between multiple matches/games scheduled on the same day provide sufficiently for adequate rest and recovery and for the safety of the young athlete.The specific impact of previous competition-related physical activity and heat exposure on subsequent same-day physiologic strain and on performance has not been examined well in youth. However, the potential for physiologic “carryover” effects from previous same-day strenuous physical activity has been demonstrated by Bergeron et al. (15) In this research, healthy young athletes (nontennis) were examined during two 80-minute intermittent exercise sessions in the heat with a 1-hour rest and recovery period in a cool environment between bouts. Even with ample hydration and body core temperature returning to baseline before starting the second bout of exercise, a 1-hour rest and cool-down period was not sufficient to avert greater perception of effort and, for some children, greater cardiovascular and thermal strain during the second session of identical exercise. In fact, such “ideal” conditions are not typical of hot-weather youth sports tournament scenarios because players often do not have the opportunity to rest immediately and recover adequately in a cool location. Accordingly, it is less likely that, when given only 1 hour or so between matches/games, a young athlete will begin the next round fully recovered. This outcome is especially true following a very long, intense contest involving a heavily sweating older adolescent, who might be facing a substantial body water and sodium deficit at the end of play.A number of notable chronic clinical conditions and medications can contribute to decreased exercise-heat tolerance and increased exertional heat illness risk. These disorders include diabetes insipidus, (32) type 2 diabetes mellitus, (33) obesity, (34,35,36) juvenile hyperthyroidism (Graves disease), (37) and cystic fibrosis. (38) Similar effects can result from the use of anticholinergic drugs and certain other medications that inherently affect hydration or thermoregulation (eg, a dopamine reuptake inhibitor used to treat attention-deficit/hyperactivity disorder or enhance performance (39) and diuretics). Other chronic or acute medical conditions (40) that adversely affect water-electrolyte balance, thermoregulation, and exercise-heat tolerance must call for particular concern and monitoring as well. Notably, a history of concussion may increase the risk of exertional heat illness, secondary to autonomic nervous system dysfunction. (41,42) Sickle cell trait also should be considered a possible contributing clinical risk or complicating factor for vascular dysfunction, exertional rhabdomyolysis, and collapse related to red blood cell sickling in youth athletes during strenuous physical activity in the heat. (43,44,45)Current or recent illness increases the risk associated with participating in physical activity in the heat because of the potential negative residual effects on hydration status and regulation of body temperature. The risk is especially significant for illnesses involving gastrointestinal distress (eg, vomiting, and diarrhea) or fever. A prior episode of EHS, however, generally does not have long-term negative effects on subsequent thermoregulation, exercise-heat tolerance, or exertional heat illness risk, especially for those who received prompt cooling therapy. (46)Exertional heatstroke is the leading cause of preventable death in youth sports. The American Academy of Pediatrics (AAP) maintains that, with sufficient preparation, appropriate modification of known contributing risk factors (Table), and close monitoring, exertional heat illness usually is preventable. Accordingly, most healthy children and adolescents can participate safely in outdoor sports, even when it is hot. (8) This latest AAP policy statement, as with other recent guidelines designed to reduce exertional heat illness risk in high school sports, (47,48) puts a strong emphasis on acclimatization, that is, allowing youth athletes to get used to the environment progressively, increasing the intensity and duration of practice and conditioning incrementally, and altering uniform and protective equipment configurations progressively.There are other essential elements of preseason conditioning and practice periods and other offsetting measures to reduce exertional heat illness risk that become more urgent as conditions and circumstances warrant. These essential elements, along with appropriate acclimatization, are the foundation of the AAP recommendations selected below to improve safety for youth athletes in the heat.Exertional heat illness in youth sports includes a spectrum of clinical conditions that range from muscle (heat) cramps and heat exhaustion to life-threatening heat stroke that result from moderate to vigorous repeated or long-term physical activity typically in hot or humid conditions. As emphasized throughout this review, EHS and other heat-related illnesses in youth sports are preventable in almost all cases if the contributing risk factors are considered and addressed sufficiently with the appropriate recommended offsetting measures. Early recognition and prompt, effective treatment of exertional heat illnesses also can readily and successfully reduce the incidence of severe heat illness and heat-related catastrophic events in youth sports.In contrast, comparatively sudden-onset, exertion-related muscle cramping that is localized (eg, affecting solely the calf), constant, asymmetric, and responsive to passive stretching and massage is highly likely to have been prompted by muscle overload and fatigue. The athlete afflicted with exertional heat cramps must be treated promptly with an oral high-salt solution or intravenously. Massage and icing can be applied to assist in relaxing the muscles and relieving some of the spasms.Heart rate, respiratory rate, and central nervous system (CNS) status should be monitored closely. If possible, blood pressure and rectal temperature also should be monitored. If an elevated body core temperature is suspected and signs of CNS dysfunction are present, EHS cooling therapy should be initiated immediately (see below) and emergency medical services (EMS) activated.A rectal temperature greater than 104°F (>40°C) should prompt immediate on-site whole-body rapid cooling using proven techniques (cold- or ice-water immersion is the preferred, most effective method, although applying ice packs to the neck, axillae, and groin and rotating ice-water–soaked towels to all other areas of the body can be effective as well). This process should be continued until the rectal temperature reaches just under 39°C (∼102°F) or the athlete exhibits noticeable clinical improvement.If rectal temperature cannot be assessed in a youth athlete who has clinical signs or symptoms suggestive of EHS, rapid cooling for 10 to 15 minutes should be initiated promptly while awaiting the arrival of additional medical assistance. It is important to initiate EMS communication immediately for any child or adolescent who collapses or exhibits moderate or severe CNS dysfunction or encephalopathy.When children and adolescents are involved in sports practice or competition, any significant deterioration in performance with notable signs of struggling and developing exertional heat illness should be sufficient reason to stop participation immediately and promptly seek medical attention. Moreover, any young athlete experiencing exertional heat illness should not return to practice or competition for the remainder of the current practice or training session, game, or match." @default.
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• W4206119364 title "Reducing Sports Heat Illness Risk" @default.
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