A 12-year-old female came to clinic for health maintenance and a sports physical. She was entering 7th grade and wanted to run cross-country. When asked about other sports and activities she said that she had started strength training as she wanted to participate in body-building competitions. She was doing the strength training at the local recreation center without supervision while her mother was swimming. Additional history revealed that her parents and 2 older siblings were active people who ran, biked and swam. She had an uncle who did weight training but did not do competitions. She had seen some body-building on television and said she liked how the people looked and understood that it was a good way to be active and be healthy. Her goal was to enter a competition in a couple of years. She liked running and biking and had entered local races with her family, but thought that body-building was something different to do than the rest of her family. She and her mother denied excessive exercise, or disordered eating. She did not appear to have a distorted body image of herself and acknowledged that body-builders sometimes can not look healthy. The past medical history showed an ulnar fracture from falling off playground equipment, but no athletic injuries. The family history showed diabetes, stroke and heart attacks in older relatives. The review of systems was negative.
The pertinent physical exam showed a healthy female with weight at the 15% (36.2 kg), height at the 50% (151 cm), and BMI of 15.9 (5%). She was Tanner stage 3 for breast and pubic hair development. The rest of her examination was normal. The diagnosis of a healthy female was made. The family was counseled about strength training in children and adolescents, and the pediatrician did not recommend body-building as she was not skeletally mature. The mother agreed with having a more structured approach to the strength training and to monitoring her daughter’s weight. The patient’s clinical course 4 months later showed that she had competed in cross-country and was now swimming both of which she greatly enjoyed. She was doing some strength training under the guidance of physical education teachers and coaches at school 1-2 times/week. She continued to gain an appropriate amount of weight and did not appear to be losing excessive fat or becoming more muscular appearing. She denied disordered eating or body image. She was now less interested in body-building but did like the weight training as she felt it made her stronger for her other sports.
Exercise is an important part of health and daily life. A review of recommendations for general exercise for children and adults can be found here. Many people use pedometers as a marker of their activity and a list of activities and their equivalent steps can be found here.
The benefits of strength training includes improved performance, injury prevention and rehabilitation, improved cardiovascular fitness, improved bone mineral density, improved blood lipid profiles and mental health. Improvements in strength can be found in properly structured programs of at least 8 weeks duration occurring at least 1-2 times/week. Strength training more than 4x/week does not add to strength and may lead to overuse injuries.
The most common risk is injury and most of these “…occur on home equipment with unsafe behavior and unsupervised settings.” Children with hypertension, seizures and obesity should be evaluated first and monitored closely. Children with Marfan syndrome, congenital heart disease, or history of cardiotoxic medication such as chemotherapy are often counseled against participation but should be appropriately evaluated and counseled.
Body-building involves strength, endurance, and flexibility and balance as integral parts of the sport. Additionally there can be additional benefits such as improved nutrition (including possibly lower cholesterol and bone strength) and improved stress management. The International Federation of Bodybuilding and Fitness has a number of competitions and programs. Fitness competitions for children in a fitness category for as young as 8 years of age are sponsored and rules can be seen here.
Other counseling issues regarding strength training include discussing with the child, teen and family the possibility of eating disorders, distorted body image, and the use of anabolic steroids and other substances.
The American Academy of Pediatrics (AAP) recommends not to begin strength training until at least 7-8 years or when balance and postural controls skills have matured to adult levels which is around this age. There are other general pragmatic considerations too. The child should be able to listen, wait, understand and follow instructions of an adult. They should have some body sense and control over their body so they can perform the exercise properly, and make the necessary adjustments when they are not doing it properly. Children should be enjoying the activity and not feel coerced to initiating or continuing the activity. These are sensible considerations for any sport. Children and adolescents should perform more repetitions of the exercise using a low amount of weight (i.e. increased weight with fewer repetitions is not recommended). Explosive, rapid lifting of weight is not recommended. Similarly there are no specific ages when an adolescent can begin power training, body-building, or maximal lifts, but many experts including the AAP recommend after the adolescent is skeletally mature to mitigate the risks to the bones, tendons, ligaments and muscles themselves.
Prepubescent children and early adolescents will generally not have muscle hypertrophy but will have recruitment of muscle groups so that they will be better able to perform the exercises. The strength training therefore helps to improve muscle skill for performing the exercise which can translate to improved skill with the sport.
It is important that children and teens have supervision so they can learn to perform the exercises properly initially, receive feedback and have ongoing monitoring so that they continue to perform the exercises properly. Supervision also about numbers of repetitions and weights for workouts can also be devised and monitored. Children and adolescent also do not always use the best judgement and adult supervision can help to ensure safety in the weight room.
Questions for Further Discussion
1. When should children begin competitive sports?
2. When should children begin elite sports?
3. What are medical conditions that preclude particular sports?
- Symptom/Presentation: Health Maintenance and Disease Prevention
- Specialty: Orthopaedic Surgery and Sports Medicine
- Age: School Ager
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
American Academy of Pediatrics Policy Statement. Overuse Injuries, Overtraining, and Burnout in Child and Adolescent Athletes. Pediatrics. 2007:119;1242.
American Academy of Pediatrics Policy Statement. Strength Training by Children and Adolescents. Pediatrics. 2008:V121;835.
American College of Sports Medicine. Youth Strength Training. Available from the Internet at: http://www.acsm.org/docs/current-comments/youthstrengthtraining.pdf (cited 4/1/14).
American College of Sports Medicine. Preseason Conditioning for Young Athletes. Available from the Internet at: http://www.acsm.org/docs/current-comments/youthstrengthtraining.pdf (cited 4/1/14).
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
8. Health care services aimed at preventing health problems or maintaining health are provided.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital