The Outside Hospitalist: Getting Back in the Game

Dr. Kade Goepferd: This is Talking Pediatrics, a clinical podcast by Children’s Minnesota, home to the Kid Experts, where the complex is our every day. Each episode, we bring you intriguing stories and relevant pediatric health care information as we partner with you in the care of your patients. Our guests, data, ideas and practical tips will surprise, challenge, and perhaps change, how you care for kids.

Welcome to Talking Pediatrics. I’m your host, Dr. Kade Goepferd. Did you know that the majority of pediatric health care happens outside the tertiary hospital setting? On today’s episode, the outside hospitalist host, Dr. Gabi Hester, discusses providing health care when you’re limited to what’s in the overhead compartment, the critical access ed or your own backpack, and how to translate these lessons to your pediatric practice.

Dr. Gabi Hester: Today I am really excited to talk with two guests about topic that I’m really always passionate about, which is sports and how we can keep kids safe and participating in these activities that we know are really important and were foundational for my own upbringing and development. I was a complete sports fanatic as a kid, really balancing that nerd stereotype with the soccer slash skier. I’ll be joined today by Dr. Laura Nilan, who is a pediatric emergency medicine physician at Children’s Minnesota plus practices full-time at TRIA Orthopedics and I am recently learning and excited to hear more is on the US Olympic medical staff. So super excited to hear more about that. I’ll also be joined by Micaela Kelso-Otieno, who is a certified athletic trainer and has decades of experience in both the high school and collegiate setting. And so we’ll get to hear more about where she’s been and what sorts of sports and kids she’s getting to take care of. So thank you both for joining me today. I’m excited to talk to you.

Dr. Laura Nilan: We’re excited to be here. Thank you for inviting us.

Micaela Kelso-Otieno: Yes, thank you.

Dr. Gabi Hester: I think one of the things I want to start with is just hearing about what your own sports experiences have been like, particularly in childhood. I think as I’m entering my middle ages, we’ll say that my sports experiences are slightly different from they were when I was in my high school athletic prime. What did you guys play or what were you involved with in your own sort of youth?

Micaela Kelso-Otieno: So when I was growing up, I lived in a very small town, so we were able to do kind of anything that was offered. There wasn’t a lot of competition for that. In high school I did basketball and in Michigan where I grew up, basketball was in the fall for girls. It has recently changed, but in the late nineties and early two thousands it was in the fall. So I did cross country and basketball. In the fall, they needed enough people to make the cross country team a team. So they recruited some of us. And then I actually played ice hockey in the winter instead of volleyball. Volleyball wasn’t my thing. And then I did track and field in the spring.

Dr. Gabi Hester: What about you, Laura?

Dr. Laura Nilan: So I grew up literally the epitome of the multi-sport athlete. So I grew up dancing. Initially I had to decide between dancing and competitive swimming. I wasn’t good enough at either one to be really good, so I ended up choosing swimming. So at the high school level, I did swimming speed skating, track and field and soccer and then transitioned that into boxing in college. So I started boxing when I got to college. And then as an adult now I do long distance swimming and long distance triathlons. So I continue to compete at the just local level for triathlons, but took the multi-sport and turned it into just doing one sport that is all three sports.

Dr. Gabi Hester: I love it. So it sounds like we have some wide variety of sports that we’re representing here. I was soccer, volleyball, tennis, and cross country skiing were my big formal sports, but downhill skiing and road biking and mountain biking and things like that are also things that I love and still love. Now as an adult, I wanted to talk a little bit about some sport specific things that we’ll get into today, but also just sort of general advice that we’re thinking as pediatricians, as general providers, how we can be talking with families about preparing their children for athletics, about how they should be having conversations about how do you choose which sports you’re participating in or what the strategic approach might be. And then of course once they’re in the sports, what are the things that we should be looking out for? What are some red flags that maybe some issues are coming up and arising that we need to address as medical providers? When you guys think about sports and the things that we as providers can be connecting with families on, are there particular ages where you think that starts to be something that families should be addressing?

Micaela Kelso-Otieno: I think now it’s happening earlier and earlier. My 9-year-old son, so he’s going to be a fourth grader. There’s already kids that he plays hockey with who only play hockey and I think at nine years old that’s probably a little bit young because they have a lot of hockey left in their life. The chances that they’re not going to want to play anymore I feel like are pretty high. I think you risk the chances of them developing an identity with only hockey and then all of a sudden they don’t play anymore. They don’t know who they are. And then I think also just with the overuse injuries, if they’re only doing one sport, one skill, they’re not developing all around strength, agility, balance, those kinds of things. So I think running the risk of selecting your sport so early or sports specialization so early, it’s becoming a problem because it’s such a real thing.

Dr. Laura Nilan: And I would echo what Micaela said From a developmental standpoint, most of our young athletes would do better doing multiple sports and that it helps them develop different muscle groups. It emphasizes different things for their body and it does reduce the risk of injury if we let our kids do lots of sports and if we let them have free play. I think people focus so much on organized sports and forget about the free play, the kid that’s just riding their bike or the kid that’s hanging upside down from the monkey bars, that is a form of sport that we need to recognize here in the U.S. We force our kids into sports so young and force them into organized sports. If you look at the European models, they don’t do sports specialization. So soccer for example, in most countries, they won’t start doing organized soccer practices until 10, 11, 12 years old.

And here we start them at like three and four and they don’t have the attention span, they don’t have the skillset to be a soccer player at the young age, the focus should be on the kids having fun and not on performance. So keeping score really shouldn’t happen until they’re really middle school age. And at the younger age it should just be Let’s go have fun, let’s learn teamwork, let’s learn about self-confidence, let’s learn about winning and losing gracefully in the fact that my 4-year-old is like, “Mom, we won our soccer game. And I was like, oh, did you? And he goes, I think so.”

Dr. Gabi Hester: So I definitely see that happening for some kids and some families getting pretty serious about things early on. And do you think that’s new? Do you think that was happening when we were kids and we just weren’t part of that?

Dr. Laura Nilan: It’s new. If you look at professional athletes, if you look at players in the NFL, most of them were two sport athletes up until college. That is changing now with the focus on single sport. But Urban Meyer who coached Ohio State and coached Florida would only recruit two sport athletes. He would not recruit anybody who just played football because he wanted them to have the body awareness for sports. And so I think when we were growing up, we’re all similar in age that it wasn’t a focus on you had to do one sport year round. Each season I had a new sport and I was okay at all of them. I wasn’t fantastic. I wasn’t going to go to college on any sports scholarship, but I had a lot of fun. I made friends and I think the focus has gone away because of the money in sports. The focus has gone away from fun to performance.

Micaela Kelso-Otieno: We had a lot of kids who came to this small college to play sports and they picked the college based off of their sport, not based off of the program. They wanted to study where they wanted to go. It was well, they gave me the most money and it wasn’t even that much money a lot of times, but it was money. And I think also on the flip side a little bit, not to put the parents on the pedestal or whatever, but I think a lot of times the parents lived vicariously through their kids. You’re going to go to college to play a sport. We spent thousands of dollars on that club team for you to make that club team for you to play that club team. Now we’re going to get our money back. We want to keep watching you play. You’re going to go to college and play a sport.

So a lot of times by the time they got to college, they didn’t want to play anymore. They’re like, I don’t want to spend six hours a day at the baseball field. I’ve done that. I just want to be a kid. I want to be a college kid. A handful of them every year didn’t make it past freshman season. They just decided, I don’t want to do this anymore. This is more than I want to commit to. I’ve done this for 10 years, I’m done. So I think a little bit too with the sports specialization is by the time they get to be old enough to be really good at that sport, they’re mentally done.

Dr. Gabi Hester: Yeah. That idea that parents may be wishing something for their children that perhaps is a little bit different from the kid and their own desires, how can we as health care providers recognize that or talk to families about that, particularly getting to them early on so it’s not something that they’re putting their kid through in those high school years where there’s already enough tension. Laura, do you have conversations with families when you’re seeing them?

Dr. Laura Nilan: I do talk to families. Every opportunity I get about participation in sports, they come in for an injury. My rule of thumb, and I think a lot of the pediatric sports medicine rule of thumb is that no more hours per week than age old. So if you’re six, you shouldn’t be doing one sport more than six hours a week and then you should take three months off of each sport. So you can play hockey for nine months, you can play soccer for nine months. They can overlap, but you shouldn’t be playing any sport year-round and at six years old, no more than six hours for one sport. And that’s kind of a simple rule.

Micaela Kelso-Otieno: And I would say too, even going into the college world, our team doc, we had an orthopedic physician that worked with us and specifically with baseball, a lot of college baseball players would play in the summer actually up here in the North Woods League. And then they would go back to college in August and they would start fall ball and they had no time off. And our team doc made it mandatory to speak with the coach, got the coach on board, which was not easy, but told the coach and the kids, if you’re going to play a summer league, you are not playing fall ball. So he made them choose, you either take the summer off or you take the fall off because inevitably if we did not do that, they would end up injured.

Dr. Laura Nilan: And pro athletes take three to four months off after their season and these are the people making millions of dollars. And if they’re taking time off to let their body recover, why are we expecting our youth to not take time off and recover their body? They’re just like the rest of us. They need their sleep, they need their nutrition and they need their time away from sports to be kids.

Dr. Gabi Hester: Are there certain sports where you see that as a higher risk, that sort of overuse injury? Are there some sports that are higher risk than others maybe for that?

Dr. Laura Nilan: All of them are at risk. Some of the biggest people that push the envelope, gymnastics early on, figure skating. So sports that require early sports specialization in Minnesota, hockey people play hockey year round, it’s 90 degrees outside and they’re like, oh, I got to go to the hockey rink for seven hours. And then volleyball recently has really become a big year-round because it’s indoors. So anything that’s indoors is going to be more pushing the envelope for playing year-round and encouraging the athletes and all those sports are extension based sports, which puts you at risk of a lot of injuries including those back stress fractures that are something that we all are so worried about.

Dr. Gabi Hester: Micaela, from your standpoint, are there areas as a trainer that you see? This is where I’m really seeing those injuries, particularly say in the high school age group of kids who are maybe spending more time on a single sport than they should be.

Micaela Kelso-Otieno: Where I used to work was in Nebraska and volleyball is huge in Nebraska. You can be on a club volleyball team from a very young age and kind of like she said, it’s all year round and even at the college level, they have a long preseason. They play games from the end of August until November, middle of November, playoffs go past Thanksgiving I think, and season starts. Well pretty much in January when you get back to school, they have some off season training, which is when they do their strength building. So they’re hitting the weight room hard in January and February and then after spring break in March they come back for spring season where they’re in the gym. That’s a pretty, I think year round sport a lot of times. And then the kids that I worried about a lot at the college level were our cross country runners because they ran all summer in preparation for cross country season.

They ran cross country season, which at the college level is long. It goes into November as well. And they have a month off and they start indoor track in January and they train hard and run indoor track and then they have outdoor track and that gets you to June and then you start training again for summer across country. So those athletes, we really had to find some time to shut them down, but a lot of times when we shut them down, they came back injured. So then they never wanted to stop running because they said, well, last year you made me take two weeks off and I came back hurt. So we had to find ways to give them active rest, yoga, elliptical, swimming, biking. We kept them moving but without the pounding.

Dr. Gabi Hester: We talked a little bit, Laura, about sometimes you see families with injuries and that’s a touch point where you might bring this topic of sports specialization and trying to move from that to more of a well-rounded approach. A lot of the people who listen to this podcast might be a primary care provider and I am a hospitalist, so I am thankful to say maybe or embarrassed to say, that I have never done a pre-participation exam. I think you referred to it in our prep conversation as a PPE, which would be that sort of sports physical that providers are doing before the season or before school starts. What should that look like? What should that pre-participation exam, what should that cover? What are providers doing in that and what would your recommendations be for an approach for that visit?

Dr. Laura Nilan: The PPE is not the patient’s yearly physical. So the PPE is really focused on looking at things that would put the child at risk with sports participation. And so I encourage families to not have the PPE be their yearly exam, that it should be a separate thing and they need to make an appointment either in their primary medical home, which is the ideal place to do it unfortunately, because we’re looking at adolescent athletes, they don’t tell mom and dad and they’re like, I need it done tomorrow. And you’re like, where do I go to get it done? Ideally it’s done in the medical home if we can get it done in the medical home with a provider that knows them, but each state has a different form to fill out. Minnesota’s is pretty comprehensive, but things I’m looking for in the PPE, so the biggest thing is what are some things that’s going to put them at risk?

It’s a great opportunity to look at blood pressure. Do they meet the guidelines? Is there hypertension? Is this something we can identify early? The biggest thing I see disqualifying athletes from participation is eye exams. The kids that don’t pass their eye exams, you have to have 20/40 vision in the state of Minnesota in order to pass your eye exam for the school. Physical kids that come in without their glasses on, I mean it happens. I just have them go back and have it rechecked. But if it’s an opportunity for us to identify a kid who may be at risk and then the heart and concussion stuff. So hypertrophic cardiomyopathy is the big thing, but I also screen for other things. My questions to the kids are, do you get out of breath when you’re running more than your colleagues? Everybody’s like, yeah, when I’m doing killers I get out of breath, but so is everybody else.

Do you identify you’re out of breath more than your colleagues? Do you have chest pain when you’re doing any sort of exertional activity? And then family history, is there any family history of early sudden cardiac deaths? Anybody with a heart attack, young history of hypertrophic cardiomyopathy or in sports medicine world? We have to use abbreviations for everything in medicine. So those are things I’m looking at. In Europe, they do EKGs in the U.S. we don’t do them, but that may be coming down the pipeline. There’s some good data coming out of the University of Washington and then concussion. So I talk about how many concussions you have, what’s the recovery, what’s your risk? So if somebody’s running cross country, low risk of concussion, I mean you could still hit a tree I guess, or you could faint your contact sports and anything that’s contact. So even baseball’s considered a contact sport because they can run into each other, asking the concussion information, the heart stuff, and then on exam, making sure they don’t have any big asymmetry on exam with their musculoskeletal exam, that would put them at risk.

Dr. Gabi Hester: Going back to the cardiac stuff for a second, if there’s a positive screen on that, let’s say there’s a family history of sudden cardiac death, what would you recommend then that provider does as their next part of their evaluation?

Dr. Laura Nilan: So if there is any red flag symptoms, I do not clear them. We need to do further workup before you can participate in high school sports, both children’s and the groups in town in Minneapolis, we have a really great relationship with them in sports medicine. And so I’ll call the cardiologists and say, “Hey, I have this kid who is looking to do sports and they have a positive screen. Can you get them into your clinic?” And they’re usually really good at getting them in within a couple days and sometimes the kid needs an echo, sometimes they need an EKG, but I refer them to the cardiologist for heart stuff or if there’s a lot of concussion stuff, I refer them to neurology or a concussion clinic.

Dr. Gabi Hester: Let’s say hypothetically you lived in an area that didn’t have a lot of pediatric cardiologists or pediatric neurologists. Are there things that primary care providers could do in their clinic to start things or to connect virtually even

Dr. Laura Nilan: Physical exam is going to be really important. So listening to the heart, one of the big things I do is the murmur for hypertrophic cardiomyopathy. There’s really not a murmur, but occasionally you can exacerbate the murmur if you have the patient, I have them stand up, I listen to them and then I squat down with them. And if that murmur gets louder when you squat with that athlete, that’s concerning enough that they probably need an echo. And so if you don’t have a pediatric cardiologist nearby, you can always get the echo and then you can have a phone visit or a virtual visit with the cardiologist to say, “Hey, here’s what I did. I had this concern.”

Dr. Gabi Hester: If you’ve had a positive screening for cardiac questions, does an EKG give you any information that might be helpful? Determining maybe prioritization of next steps.

Dr. Laura Nilan: Getting an EKG if there is a positive screen can be helpful as a, well look at your EKG looks normal. Some of those kids just need to drink more water or eat more salt or just eat more calories. But there are those kids that we are concerned about cardiac and so EKG is a great first step in the office if you have access to it as a screening tool, but it’s not recommended currently by the American Academy of Pediatrics or the American Medical Society for Sports Medicine.

Dr. Gabi Hester: Yet not a universal screening for every kid coming in for that pre-participation exam. Not recommended to have an EKG and all those kids, but potentially if they have a concerning cardiac history or something on exam that is making you think cardiac as a potential issue. We’ve touched briefly on concussions. I am going to be an assistant soccer coach again this summer. They take concussion really seriously, even sort of at that age just to be an assistant coach, I had to complete a rigorous online course called Heads Up, I believe was the name, talking about concussion prevention, concussion response as an assistant coach for the team. So let’s just redefine what a concussion is and maybe what it’s not and what we’re talking about here when we’re talking about concussion.

Micaela Kelso-Otieno: I like to dumb it down and just say a concussion is a bruise on your brain.

Dr. Gabi Hester: Just like, oh, I love that.

Micaela Kelso-Otieno: Got hit in the thigh when you’re playing soccer and you have a bruise on your thigh and it doesn’t function very well. A concussion is a bruise on your brain. You have a bruise on your brain, it’s not going to function very well. That’s how I used to kind of explain it to the college kids when they were just like, no, I’m fine. I’m like, well, you’re not fine. It’s not working. Your brain is not working just like your thigh wasn’t working last week when you got hit. I don’t know if this is a great analogy, but it’s one that I used with them and they’re like, well, I’m just a little bit concussed. And I would say, no, you’re not. You’re either concussed or you’re not. And I said, it’s like being pregnant. You’re either pregnant or you’re not. You can’t be a little bit pregnant, you can’t be a little bit concussed. And once I gave it to them on that level, they were also like, oh, okay.

Dr. Laura Nilan: Suppose when we’re doing concussion, the big thing that we see in sports medicine is A, we diagnose them and then B, how do we get the athletes back before they can get back to sports? They need to recover. And there’s a whole guideline. Every state has a return to play protocol on the state high school league. I literally will print that off for families and show it to them the five-day return to sport. And it takes longer than five days usually, but they call it the five step return to sport.

But when kids have a concussion, I tell parents, you need to get some blood flow to the brain. So I love family walks, so you have to be able to talk in a full sentence and not work up a sweat. That’s a family walk. Kids can do that when they have a concussion. It’s okay to let them do some social media if you do that with your family or contact with friends because so much of their identity is around the sport and if we pull them away from their friends, we’re pulling them not only away from their sport, from their social life. So I love to let them have a little bit of interaction with their friends. Do I let them go to the Friday night football game? Probably not. I would recommend against that. So you’re going to want to find some activities that allow them to still be with their friends or be doing social activities, but still giving them time to rest. So I will not clear an athlete to go back until they do not have a headache. They do not have dizziness, they feel a hundred percent themselves and they are fully returned to school before I will return them to sport.

Dr. Gabi Hester: How does that practically work out both for you and then what a provider out in the community might do if they were general provider taking care of this kind of thing?

Dr. Laura Nilan: This is where I love athletic trainers. I utilize them so much because the high school based athletic trainers know the students. And in the state of Minnesota, if I’m the team doc working with a team, I can’t manage all the kids. I’m not there. But the athletic trainers are there every day in the training room and can take them through the return to play protocol. If there’s any concern they can reach out to me, but they can help get the athletes back to sport. Even some of the smaller rural schools do have an athletic trainer, so utilizing your athletic trainer to take them through the return to play protocol and get them back to sport

Dr. Gabi Hester: Micaela, so if you have a kid who, let’s say you’re working with a team at a soccer game, the kids looking funky on the field after a big header or something, what are things that people on the sidelines should be looking for that might indicate that there should be a little pause and an evaluation? What does that look like?

Micaela Kelso-Otieno: If there’s any big hit on the field, we’re going to check them out. But as an athletic trainer, I would always just watch the kids. I mean, I was there every day with them, I mean day in and day out for months and over the course of their college career for years. So I learned those kids. I knew what their normal running looked like, I knew what their normal play looked like, and if all of a sudden they’re kind of turning in circles and they don’t look right, I get them off the field. I’m like, coach, we got to pull that kid. Maybe you can put him back in. Well, in the second half they could. In the first half they couldn’t, but we got to look at so-and-so at least call him over to the sideline, pull him out of the play so to speak, but keep him on the field for a second.

Let me talk to them. So a lot of times I would just walk over and just be like, “Hey, Joey, come over here for a minute. Are you okay? You’re looking weird on the field. Did you eat a bad lunch or did you get hit?” And I think that’s where the athletic trainer comes in too, in the fact that I had a relationship with these kids. They knew that if I was asking them a question, it’s because I genuinely cared about them, not because I wanted to be malicious and pull them from the game of their life. I wasn’t trying to take them out of a game that they loved. I wanted to make sure that their brain was going to be a hundred percent when they were trying to run and play with their children in 10 years. And that’s what I always tried to reinforce to them is I’m not trying to ruin your life. I’m trying to enhance your life for later when you’re an adult.

A lot of times I’d check them at halftime, that’s a great time. They’re sitting on the bench, their adrenaline is coming down. A lot of times symptoms don’t come out right away. But then 15 minutes of halftime, they’re on the bench, their heart rate’s coming down, their adrenaline’s subsiding a little bit, and all of a sudden they’re like, oh, I don’t feel good. They’re dizzy. They have a stomach ache and they have a smashing headache. Well, at that point we’re done. And then I can take them through the sideline testing too, but a lot of times it’s purely incident. Did they get hit and symptoms? What are they feeling?

Dr. Gabi Hester: Those kids ever going back into that game? I mean, if you feel nauseous, you’re not going to go back into play, right?

Dr. Laura Nilan: There’s a law.

Dr. Gabi Hester: Oh, I just saw that. Okay.

Dr. Laura Nilan: It’s a national law called Lystedt Law. So if you have signs, incentives of a concussion, you cannot go back into a game.

Dr. Gabi Hester: And who would be held accountable?

Dr. Laura Nilan: Coaches in the state of Washington, there was a coach that was held accountable for a young football player that went back into a game with a concussion and suffered second impact syndrome and had his life drastically changed, he survived. His life was never the same.

I always say trust a little man on your shoulder. If you’re a parent coach, let’s say you’re a U10 game, there’s not going to be an athletic trainer there, U12. We all have that little person that’s like, something’s not right. If that person’s saying something’s not right, it’s okay. Take them out, talk to them. And I tell parents, I’m like, listen, I know it’s really disappointing. And tell the athlete it’s disappointing to not be able to do something you love to do and I’m really sorry, but I need to protect you. I’m concerned about a concussion and I use the law. I’m like, there’s a law that says that there’s concern for a concussion. I can’t let you go back in the game today.

Dr. Gabi Hester: Is this a newer type law? Are parents and coaches aware of this?

Micaela Kelso-Otieno: The Zackery Lystedt case was, I think, the early two thousands, but I don’t know how long it took for that law to come out. And then each individual state also passed their own law. So each individual state kind of has their own legislature, so to speak on it too. The college I started at was in 2010, and at that point Nebraska did not have a law, but it was passed shortly after.

Dr. Gabi Hester: Is there a role for head imaging ever when a child is having concussive symptoms?

Dr. Laura Nilan: Your concern for a skull fracture or hemorrhage, that child needs to be evaluated in the emergency department. There’s a whole set of guidelines in the emergency department for who needs head imaging. There’s no head imaging, there’s no test, blood test or anything like that looking for concussion. It’s strictly a clinical diagnosis. Sometimes if they’re having post-concussive syndrome, they’re really struggling to recover, then neurology gets involved and they may do MRIs. But in the acute injury, there’s not really a role for head imaging for concussion. It’s only for head bleeds and skull fractures. I think too with concussions, I think helping families to understand expectations with concussions. So if your kid has a concussion, they’re not playing the next day average adolescent. So average takes two to four weeks from the date of injury until they’re fully back in game situations, two to four weeks and up to three months can be normal. I think managing that expectation early on that big tournament next weekend, unfortunately you’re not going to be ready for that most likely. And I think it’s one of the hardest parts of my job is telling an athlete they can’t play.

Dr. Gabi Hester: I’m guessing that there are coaches and parents who really appreciate each of you, Laura, Micaela, being the messenger, right? Because it’s a hard message to deliver. And so rather than a parent having to be the one telling their kid and the kid being potentially mad at them or the coach, it may sometimes be good to be that a little bit more neutral party.

Micaela Kelso-Otieno: I mean, another way that I would bring it to my college athletes too, and they’re like, I can’t play this weekend. And first of all, I would bring up the five to seven day exercise progression and I said, there are purely not enough days to get through this progression. So that right there tells me that you’re not playing this weekend. But then I always just look at them and I’m like, “how good do you really feel right now?” And they’re like, “well, not that great.” And so I’m like, “how great would you play? So do you want to play in a game where you’re not going to be at your best, you’re not going to feel good, and you could potentially make how you feel right now, linger longer. Do you want that? Because looking down the road, you have your conference tournament in four weeks.”

If you try to go do this and rush this, there’s no way you’re playing in that tournament in four weeks. So if I kind of laid that out to them and it was like a, you’re not going to be at your best, you’re not going to have a great performance and you’re going to potentially affect a bigger game situation later. And that would kind of get them thinking. And so in that respect, I would kind of put the ball in their court. They get to feel like they made the decision. I still made it, but they get to feel like that they have a say in it.

Dr. Gabi Hester: I want to switch gears a little bit. I mentioned in the beginning that I’m a cross country skier, and so one of my hero athletes is Jessie Diggins, who was familiar to many Minnesotans, I’m guessing since she’s from Afton, Minnesota. She was along with Kikkan Randall won the first US gold medal for the Olympics for cross country skiing. So a huge event for all of us Lycra wearing nerds out there who love cross country skiing. One of the other things that I really admire about Jessie is she’s been very vocal and transparent and putting it out there about her personal journey with bulimia. And so she wrote a book called Brave Enough, which really talks about lots of things in her life. One of which her experience with having an eating disorder and being a participant in the Emily Program, which many of us in the Twin Cities area are familiar with as a treatment program for children with eating disorders. There’s been different names over the years for what we call some of these different findings in young athletes. But I understand relative energy deficiency is maybe the term used currently, and RED, I’m guessing is the acronym for that. Can you remind me a little bit about what that is, that relative energy deficiency and how we might screen for that, how we might talk with parents and families about it, what we as sort of pediatricians or general providers can be looking for in that?

Dr. Laura Nilan: I use every opportunity with my student athletes to ask about RED S type symptoms. So we call it RED S relative energy deficiency in sports screening exams. I ask all my young ladies, do you get a period every month? What age did you get it? When was the last time you got it? And are they regular? And kids are often like, what does it have to do with my ankle fracture? And I’m like, well, it has a lot to do with your bone health is what I tell them. I’m going to ask some weird questions. It has to do with your bone health. Just bear with me if you have a young athlete. And I ask my males about sleep and about testosterone because there’s a lot of young men that are taking testosterone supplements, which can affect RED s as well. Just screening questions about dietary restrictions too.

I always ask my kids, any food groups, you don’t eat dairy-free, vegetarian, vegan, just as a broad screening question, that’s fine, especially if they have celiac. But making sure we’re getting complex carbs and there’s lots of places to get them. Or if you’re dairy free, where are we getting our calcium from? Vegans, where are we getting our vitamin B12 and our protein from? Just to make sure. And then just if they’re coming in with a stress injury or if they’re coming in with fatigue, I think those are good opportunities to talk to the athletes. Sometimes I’ll have the kids just keep a food diary, just what are you eating in a day? And then I have a very short trigger just even referring them to a sports dietician and saying, “Hey, I think we could optimize your nutrition. You might play better. Let’s just go talk with someone.” And I don’t bring up red S or anything like that initially, but I just like, “Hey, let’s just make sure we’re optimizing your nutrition for performance.” And then if there’s things that come into concern, then we start bringing in really that multidisciplinary approach.

Micaela Kelso-Otieno: I think from my experience, a lot of my conversation was more like, how are you fueling your body for practice? How are you fueling your body for the day? There was one semester that I taught a nutrition class and I had a lot of athletes in my nutrition class, and not that they had a lot of red flags for red S, but throughout the course of the class they would come to me. I made them do reflection writings on articles that they had to read. And a lot of their reflections were, I don’t eat enough, I don’t eat enough. And it wasn’t that they were trying to not eat enough, it was that they had no clue how much they needed to eat to fuel their body for practice. And towards the end of that class, it was a spring semester, so it was during track season. I had a lot of track athletes say, I am making it through workouts so much better now because I am now eating before practice. They would eat a salad at lunch at 11 o’clock and then they would go to track practice at four and expect to be able to perform. I’m like, sweetheart, that salad is not getting you very far. So getting them to focus on timing of their nutrition and quality, what they were eating when they were eating it, that was really big. And then just how much I would tell them, I know you think you need to eat 1500 calories a day, but you’re burning 1500 calories at practice. So getting them to understand that they needed so much more than that and then getting them to buy into that, especially the females, but the males too. We had a lot of males who did not consume enough calories.

The other thing was getting them to understand they had to pack this required planning ahead, which is tough sometimes for college kids, but they had to pack a snack to eat after practice because they would finish their workout, they would stretch, they would come into the athletic training room and ice foam roll, get treatment, and then by the time they wandered over to the dining hall, it was probably an hour and a half after their workout, that 30 minute window of refueling was gone. They needed that snack an hour ago. So getting them to understand that they needed a snack to eat while they were stretching protein, carbohydrate combination to refuel their body and get those muscles rebuilding their carbohydrate stores replenished within that half hour, I got them to do that. And then they’d say, “Wow, I feel so much better the next day.” That’s because you gave your body what it needed.

Dr. Gabi Hester: Let’s do some hypotheticals here. So either this is your kid or your niece or nephew or someone that you love football play or not play.

Dr. Laura Nilan: My kids are not going to play football, contact football until at least middle school.

Micaela Kelso-Otieno: My son will never play contact American football. Hockey.

Dr. Laura Nilan: Yeah, he plays it. My son is asking to learn to skate. I’m trying to push him towards speed skating.

Dr. Gabi Hester: Yes. I love it. Speed skating, soccer.

Dr. Laura Nilan: I mean the highest sport for concussion is girls’ soccer. I have two boys, so I’m okay in that one. Soccer’s fun. I don’t know. I struggle. I was a goalie. I loved soccer.

Micaela Kelso-Otieno: Yeah, I was a goalie too, my daughter to soccer. So we’re just going to keep going on that road.

Dr. Gabi Hester: Is taking headers out. Would that change the dynamic?

Dr. Laura Nilan: The biggest risk with headers is the contact with the other person’s head. Not necessarily as much the ball. It’s the contact with the other person’s head when you’re colliding. If nobody did headers, would I be okay with it? Yep, absolutely.

Dr. Gabi Hester: Gymnastics.

Dr. Laura Nilan: So my son does gymnastics. I think gymnastics is wonderful at a young age to learn body control, body position and strengthening. I pray my child does not want to go into competitive gymnastics because of the demands of the sport and the expectations at the Olympic level.

Micaela Kelso-Otieno: My daughter is begging to do gymnastics and is going to start in the fall, but I also know that I am confident enough that I can put my foot down and I know that I can put my foot down and say, no, we’re not doing that. We’re not going competitive. We’re not going to do it 12 months year round. I did the same thing with my son in hockey. Most of his teammates are doing something all summer long. They’re doing a camp, they’re playing pickup games, and I just told him, we are not doing anything from June until September. And he’s itching. He’s on his roller blades every day. He’s at a hockey stick in the street, but that’s different. He’s doing different things. He’s using different muscles. He’s racing his sister on her feet while he’s on his roller blades, and that’s on his own. So he’s itching to get on the ice. So I think I’m confident enough that I can put my foot down with the gymnastics part.

Dr. Gabi Hester: Is there another sport that I haven’t mentioned that I should shift some of my anxieties onto? Anything else you’d avoid?

Dr. Laura Nilan: Full disclosure, I did boxing. I am on the high performance team for USA boxing. My kids will never box. They will never ever put on a set of boxing gloves.

Micaela Kelso-Otieno: Mine either.

Dr. Gabi Hester: Mine either. Not that they would ever. I don’t think that that’s their future, but Interesting. So you’re okay with it for you, but not for your kids.

Dr. Laura Nilan: So I did it when I was 18 and didn’t know better. American Academy of Pediatrics does not approve of boxing. While I think it’s a very violent sport, I at least have some knowledge about the injury patterns and taking care of them. So I cover it because somebody needs to, and I’d rather have with experience and knowledge about the sport cover it than somebody who knows nothing and is not going to protect those athletes.

Micaela Kelso-Otieno: I think any sport could have pluses and minuses. So I think kind of circling back around to where we talked in the beginning of all in moderation, do it for a season and then find something else

Dr. Laura Nilan: And do different sports. Yes, I encourage people to pick sports that are different like basketball and cross country or cross country skiing, downhill skiing. We’ve got great winters in Minnesota. Pick an outdoor sport, get some time outside. There’s no bad weather. Just inappropriate clothing choices for your sports.

Dr. Gabi Hester: Ending. On a positive note, what’s your absolute favorite thing about sports?

Dr. Laura Nilan: What you learn, self-confidence that you get from doing it?

Dr. Gabi Hester: I want to make sure we end with giving our listeners something that they can turn to to get more information.

Dr. Laura Nilan: Two textbooks that I keep with me all the time. One of them is from the American Academy of Pediatrics. It is the pre-participation physical, the guidelines for that. It’s on the AAP website. I bring it to every set of schools, physicals that I do. I think it’s important. It’s got great resources in there. The other one that I keep with me and I actually have sitting next to me right now is Care of the Young Athlete. It is also through the American Academy of Pediatrics in association with the American Academy of Orthopedic Surgeons. And it just talks about everything with young athletes from nutrition to return to sport, to injury patterns to recovery. They’re under a hundred dollars each, I believe. So if you have some CME money sitting around, they’re great to pick up, great resources. And then if you go to the American Medical Society for Sports Medicine, the American College of Sports Medicine, AAP all have some great resources on sports for physicians and for other people. They have information for parents and families that you can go look up as well.

Micaela Kelso-Otieno: I used to have a little handbook that had all the special tests in it for injuries. So ones that maybe I couldn’t remember off the top my head or I remembered it, but then I’m like, wait, what is this telling me? So I had a little handbook. It was probably five by seven, maybe a little bit bigger, and I had that in my office or carried it with me depending on where I went. That was a great one. And then the ImPACT website for concussions. You could get all kinds of concussion information off the ImPACT website. A lot of it’s free. The program costs money, but there’s a lot of information on that website. There’s checklists, there’s scat tests, there’s things for coaches, there’s things for youth coaches, there’s information for physicians. There’s return to play guidelines, there’s return to the classroom guidelines. There’s a lot on that ImPACT website.

Dr. Gabi Hester: And I know we have a previous Talking Pediatrics podcast on all about concussions where I interviewed Dr. Jesse Coenen, who is a sports medicine physician and emergency medicine physician as well. So you can look back to that episode in our archives for Talking Pediatrics. And thank you both. It was super fun talking with you, and hopefully we’ll see each other out in the sports arena sometime. I’ll be looking, Laura, to recognize you by the textbooks that you’re carrying.

Dr. Laura Nilan: I literally, I carry them all the time. You can laugh, but it’s really helpful.

Dr. Gabi Hester: That’s awesome. Cool.

Dr. Laura Nilan: Look up.

Dr. Gabi Hester: Well, thank you guys. It was super fun talking with you.

Dr. Kade Goepferd: Thank you for listening to Talking Pediatrics. Come back next time for a new episode with our caregivers and experts in pediatric health. Our showrunner is Cora Nelson. Episodes are produced, engineered and edited by Jake Beaver and Patrick Bixler. Our marketing representatives are Amie Juba and Krithika Devanathan. For information and additional episodes, check us out on your favorite podcast platform or go to childrensmn.org/talkingpediatrics.