New indications for when summer football practice endangers youths

Against the backdrop of the record-breaking hot and humid summer many states have experienced and the beginning of school, or at least football practice, new guidance is available to pediatricians about which youths could be cleared for athletic participation in these conditions.

New study results have been released, warnings have been issued, and the American Academy of Pediatrics (AAP) has posted a new policy statement that adds body mass index (BMI) above the 85th percentile for age, chronic medical conditions, recent illness, and medication to the risk factors for heat-related illness for children and adolescents.

Reversing its previous position that children are less able to regulate body temperature than adults and have lower tolerance for strenuous exercise in hot weather, the AAP’s new statement relies on research that indicates that similarly fit, hydrated, and acclimated children and adults respond equally to intense workouts in challenging environmental conditions.

Medical conditions shown to increase susceptibility to heat illnesses include diabetes, sickle cell disease, and hyperthyroidism. Children taking medications that may affect hydration or thermoregulation such as dopamine-reuptake inhibitors used to treat attention-deficit/hyperactivity disorder, diuretics, and anticholinergic drugs also have increased risk. Recent illnesses, particularly those affecting the gastrointestinal system or causing fever, may also reduce an athlete’s tolerance for heat.

So far, at least 4 high school athletes have died during or after training practices for football this summer, according to the Union of Concerned Scientists, which held a teleconference earlier this month to discuss its findings on the risk factors for heat stroke among football players.

From 1980 to 2009, 58 football players-48 younger than18 years-died of heat-related illnesses, said speaker Andrew Grundstein, PhD, a professor at the University of Georgia. And, the common wisdom of practicing in the morning and drinking plenty of fluids do not provide sufficient protection to significantly reduce deaths, according to Grundstein’s previous research, which shows that 60% of heat-related deaths occurred after morning practices, when the temperature may be cooler, but the frequently higher humidity can drive up the heat stress.

“Even when athletes are well-hydrated, if it’s hot enough and you go hard enough, people can die,” according to another speaker at the teleconference, Michael Bergeron, PhD, director of the National Institute for Athletic Health and Performance at Sanford Health and lead author of the AAP’s new statement.

Two factors directly affected death rates: BMI and game position. Almost 95% of athletes who died were overweight by BMI measures. Nearly 80% had BMIs above 30, a level considered obese. Linemen, who are typically larger, were the most at risk, accounting for 86% of the deaths. The athletes’ large size may make dissipation of internal heat more difficult, research suggested.

Being male may be another risk factor. Heat illnesses resulting from physical activity in hot weather send males to the emergency department (ED) 3 times as often as females. Football causes more boys younger than 20 years to head to the ED for heat-related illnesses than any other activity, according to a Centers for Disease Control and Prevention report.

"Specific emphasis should be placed on targeting appropriate prevention messages toward those aged 15 to 19 years, who are at greatest risk, and their coaches and parents," researchers said. Young men in that age bracket account for more than one-third of all visits to the ED for heat illness after physical activity.

The AAP encourages pediatricians to educate parents and coaches about the need for acclimatization to strenuous exertion in hot weather over 10 to 14 days and the importance of having a way to rapidly lower core body temperature, ideally by full-body immersion, on-site at all youth athletic activities. In addition, coaches need to be instructed on the signs of developing heat illness, and patients should be encouraged to take frequent rest and fluid breaks during hot and humid weather, accurately report their condition, and go easy during recovery from illness.

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