Pediatric Primary Care Case Studies (41 page)

Those who are using drugs to enhance their performance should receive as much information as possible about their side effects. Such information is beyond the scope of this case study, but is available from a plethora of references and community resources. A referral for alcohol and drug assessment and counseling is in order.

Management Considerations for the Female Athlete Triad

The PPE provides an opportunity for the provider to be vigilant for features of the triad in female athletes. The presence of an eating disorder, rapid and progressive weight loss, change in menses patterns with either irregularity or loss of periods, and repeated stress fractures should prompt a team approach for management. This team of specialists often includes a nutritionist, medical provider, and psychiatrist or psychologist. The parents, athletic trainer(s), and athlete are included as part of the team. Exercise may need to be limited until the negative energy balance and unhealthy weight are corrected. If the individual is frankly amenorrheic, gaining weight through reduced training (exercise decreased to 3 days/week only if less than 85% of the estimated ideal body weight; otherwise, no change is necessary) would be part of the management strategy (Landry, 2007). If the amenorrhea has been prolonged and increasing calories is problematic, estrogen/progesterone replacement should be considered (AAP, 2002; Landry, 2007).

The female athlete may neither recognize she has a problem nor be aware of the serious physical consequences. Your education should focus on the benefits of treating the disorder in order to enhance her athletic performance–increasing strength, endurance, and concentration.

How do you plan to manage this adolescent?

Female Athlete Triad Issues

Nikola’s history and PPE have some elements that suggest early female athlete triad (stress fracture, poor nutrition, oligomenorrhea). Correction of any inadequate calorie consumption should resolve her issues completely. Therefore, you arrange for her to talk with a nutritionist (a sport nutritionist is preferable). If you had discerned a frank eating disorder, then you would also refer her to a specialist in this field in order to deal with the psychological aspects of this condition. You prescribe a calcium supplement of 1,200–1,500 mg/day and ensure that her multivitamin contains iron and vitamin D. You schedule a recheck examination for Nikola in 3 months to recheck her weight and menstruation status.

Second-Impact Syndrome Issues

You also address her risk for second-impact syndrome. Any potential contact/collision activities should involve her using a helmet (e.g., while cycling or for any aggressive downhill skiing). You get permission from her (and note it in her chart) to notify her parents about the dangers of a second head injury.

Family Planning and Lifestyle Issues

You provide her with a pamphlet on birth control options, emphasize the continued use of condoms, and encourage her to return for a prescribed method should she resume sexual activity. You also emphasize the benefits to her health, academics, and sport success of abstaining from drugs and alcohol. Additionally, you advise her to seek medical attention should she have worsening or persistent bone or joint pain during daily activities, because she would need to be evaluated for a stress fracture, runner’s knee, or other musculoskeletal disorder. Track and field sports activities have a small risk of eye trauma, but she needs to be wearing any specific recommended eyewear for her sport.

Preparticipation Permission

You give her a quantitative “yes” clearance for sports pending review of her medical records pertaining to the MVA. You receive these records a week later. They reveal that Nikola was given a diagnosis of Grade 1 concussion with some mental confusion to date, time, and event; she was watched overnight in the hospital as a precaution. She demonstrated limited recall about the event and had a mild headache a week later at the clinic; by the second recheck appoint (week 2 post-MVA), she was fully oriented, her headaches had resolved, and no further follow-up was advised. You note in her record receipt of these records, give her a diagnosis of “cleared for sports,” and mail off a copy of the sports examination form (the second side of the form in
Figure 10-1
) to Nikola.

What follow-up care do you want to plan for Nikola?

Nikola needs to return for her weight check in 3 months. You place a note in the system you use in your clinic for important recall purposes.

Additionally, you call her parents and discuss second-impact syndrome with them and Nikola’s risk factors for another head injury. You note your call in her chart.

Key Points from the Case

1. The PPE is often the only health examination for the majority of youth and adolescents in any given year. There are two parts: the musculoskeletal and general physical examinations.

2.
A standard PPE form should be used.

3. All history and physical findings need to be documented. Findings will help the provider determine whether sports participation should be allowed, whether further evaluation is needed before being allowed, or if risk factors preclude participation.

4. Psychological and physical well-being need to be assessed in order to ascertain the individual’s level of awareness of the demands of the sport, the anticipated response to these demands (experiencing defeat), and consequences of participation within the context of the time commitment.

5. Adequate nutritional intake is crucial for maintaining normal growth and meeting the added demands of the physical activity.

6. Postconcussive syndrome/second impact syndrome can be a side effect of a minor head injury; any history of a head injury needs to be fully explored before allowing participation in contact or collision sports.

7. The female athlete’s health risks are altered due to environmental, anatomic, hormonal, biomechanical, and neuromuscular factors.

8. The
female athlete triad
is comprised of a progressive set of three interrelated conditions that occur along a continuum rather than in unison: anorexia, amenorrhea, and osteopenia. The existence of one of these symptoms serves as a red flag during the PPE. Management involves a team approach.

9. Medroxyprogesterone (Depo-provera) has a “black box” warning as a contraceptive for adolescents and young adults because of a chance of prolonged bone mineral density loss; careful consideration is indicated before prescribing.

10. General counseling topics should also include preparatory training and warm-ups, heat illness prevention, eye protection, caloric needs, added minerals that may be necessary, drug and alcohol avoidance (including performance enhancing drugs), and risky behaviors.

REFERENCES

American Academy of Pediatrics. (2002). Guidelines for pediatricians: Female athlete triad.
Sportsshorts
, 8. Retrieved April 13, 2009, from
https://www.aap.org/sections/sportsmedicine/PDFs/SportsShorts_08.pdf

American Society of Health-System Pharmacists. (2008).
American Hospital Formulary Service (AHFS) Drug Information 2008
. Bethesda, MD: American Society of Health-System Pharmacists.

Blosser, C. (2009). Activities and sports for children and adolescents. In C. Burns, A. Dunn, M. Brady, N. Barber, & C. Blosser (Eds.),
Pediatric primary care
(4th ed., pp. 262–303). St. Louis: Elsevier/Saunders.

Brain Injury Association. (2004).
Fact sheet: Sports and recreation
. Retrieved July 15, 2008, from
http://www.biausa.org/BIAUSA.ORG/word.files.to.pdf/good.pdfs/factsheets/
SportsAndRec.pdf

Browne, G., & Lam, L. (2006). Concussive head injury in children and adolescents related to sports and other leisure physical activities.
British Journal of Sports Medicine, 40
, 163–168.

Cantu, R. (2003). Head injuries. In J. DeLee, D. Drez, & M. Miller (Eds.),
DeLee and Drez’s orthopaedic sports medicine: Principles and practice
(Vol. 1, 2nd ed., pp. 772–773). Philadelphia: WB Saunders.

Centers for Disease Control and Prevention (CDC). (2006).
HIV/AIDS questions and answers: Can I get HIV while playing sports?
Retrieved April 13, 2009, from
http://www.cdc.gov/hiv/resources/qa/qa30.htm

Cook, R., Hutchinson, S., Ostergaard, L., Braithwaite, R., & Ness, R. (2005). Systematic review: Noninvasive testing for
Chlamydia trachomatis
and
Neisseria gonorrhoeae. Annals of Internal Medicine, 142
, 914–925.

Davidson, M. (2003). Pharmacotherapeutics for osteoporosis prevention and treatment.
Journal of Midwifery and Women’s Health, 48
(1), 39–54.

Griffin, L., Hannafin, J., Indelicato, P., Joy, E., Kibler, W., Lebrun, C., et al. (2003). Summary: Team physician consensus statement: Female athlete issues for the team physician: A consensus statement
Medicine and Science in Sports and Exercise, 35
(10), 1785–1793. Retrieved July 15, 2008, from
http://www.acsm.org/AM/Template.cfm?Section=Clinicians1&Template=/CM/ContentDisplay.cfm&ContentID=1617

Hergenroeder, A., & Chorley, J. (2004). Sports medicine. In R. Behrman, R. Kliegman, & H. Jensen (Eds.),
Nelson textbook of pediatrics
(17th ed., pp. 2302–2320). Philadelphia: Elsevier/Saunders.