Use of performance-enhancing substances (PESs)

Performance enhancement: not just for athletes anymoreMichele LaBotz, M.D., FAAP

Use of performance-enhancing substances (PESs) traditionally has been considered an issue in athletes, and prevention and screening efforts have primarily focused on that population. However, patterns of pediatric use of PESs have changed significantly over the past few years, with reports of increased rates of use by non-athletes, primarily for appearance-related concerns. This includes use of “diet pills” for weight loss, as well as protein, creatine and anabolic agents to enhance muscularity.

An updated clinical report from the AAP Council on Sports Medicine and Fitness discusses trends in PES use and offers tips for pediatricians, parents and athletes. Use of Performance-Enhancing Substances,, will be published in the July issue of Pediatrics.
The greatest medical risk with attempts to enhance performance/appearance occurs with diversion of controlled substances, according to the report. Several classes of drugs frequently are diverted for these purposes. The following rates of non-medical use have been reported in recent national surveys of high school students: amphetamines, 12%, anabolic steroids, 7% and synthetic human growth hormone, 11%.
Protein, creatine most common
Although generally not considered as dangerous as drugs, the PESs most commonly used by adolescents typically are sold as dietary supplements. Protein and creatine are at the top of the list. Recent surveys of high school students report protein supplement use by 30% of boys and 18% of girls.
Pediatricians may find the following information helpful when counseling patients on protein supplementation:
Protein supplements typically are in the form of powders, shakes or bars. They commonly contain 20-30 grams (g) of protein per serving, which is similar to the amount contained in a 3-4 ounce (oz) chicken breast.

Young athletes may require up to 2 g protein/kilogram (kg) body weight/day (almost 70 g in a 150-pound athlete). This often is readily met with a typical American omnivorous diet.

Vegetarians and others who are restricting their diet may benefit from nutritional consultation, but several easy changes can greatly increase dietary protein intake, as follows:

Traditional yogurt has 7 g protein/6 oz serving, while Greek yogurt provides 17 g and cottage cheese has 21 g.

Nonfat dry milk contains 12 g protein per half cup. This can be added to soups, sauces or beverages as a “hidden” source of added protein.

Peanuts, almonds and cashews all contain over 20 g protein per 100 g serving.

Creatine use has been reported by 18% of 12th-grade males and almost 2% of 12th-grade females.

Creatine is stored in skeletal muscle and helps replenish adenosine triphosphate during maximal effort activities of short duration.

The body requires about 1 g ingested creatine/day, which can be found in 2-3 servings of meat or fish.

There is no added benefit to extra creatine.

Contamination concerns
Pediatricians should remind families that Food and Drug Administration regulation of supplements is much looser than for items sold as foods or drugs. However, it can be very difficult for consumers to distinguish these categories, as supplements often are intermingled on shelves with food and/or over-the-counter drugs at point of sale.
Analysis of supplements sold as PESs revealed that 25% were contaminated with anabolic steroids, 20% with heavy metals and 11% with stimulants.
Concerns regarding contamination and lack of FDA regulation of dietary supplements prompted attendees of the 2016 AAP Annual Leadership Forum to adopt a resolution calling for enhanced education and advocacy.
Risk factors, different motivation
Risk factors for PES use include: male, higher body mass index, body dissatisfaction, training in commercial gym and exposure to appearance-oriented fitness media. While use of PESs correlates with substance abuse and other high-risk behaviors, PES use typically is “goal oriented,” whereas most other substance use in adolescents is recreational. This calls for a different approach when counseling on PES use.
Adolescents base their decisions regarding PES use largely on their hope for benefit, and this significantly outweighs any potential concern about adverse consequences. Therefore, prevention efforts are best focused on the lack of benefit of PES use, and pediatricians can provide information on alternative methods for achieving their goals.
Emphasize the following when counseling patients:
The overwhelming majority of initial claims by supplement manufacturers regarding muscle-building, weight loss or performance enhancement are debunked after further investigation.

Even the most favorable studies on the effects of PESs on athletic performance cannot rival the 30% strength gains that are reported in youth strength-training studies of several months’ duration.

Adherence to fundamental principles of training, rest and nutrition remains the best way for patients to achieve healthy fitness and appearance-related goals.

Dr. LaBotz, a lead author of the clinical report, is a former member of the AAP Council on Sports Medicine and Fitness Executive Committee



We are seeing colds and Strep. Parents always ask how can they tell a minor cold from something more serious. You can not easily tell the difference. One child may have a minor cold and a sibling may have a more serious strep infection. Even a viral illness such as RSV and influenza can be life threatening. How to treat the cold symptoms are a common concern with most parents. Review my post on how to treat fever and Cold medications. Keep in mind that most uncomplicated colds will resolve within 10-14 days without any treatment.

Diphenhydramine – Benadryl dose

Usually as we approach Thanksgiving we start to see RSV infections. Around the Christmas holidays is when we usually start to see Influenza. There may be different strains of flu each year. Some years we will see both Influenza A and B. In 2009 we had quite a large outbreak of H1N1. The 2010 and 2011 were unusual in that they were mild and occurred later than usual. However 2012, 2013 , 2014 were very busy flu seasons. This year is just starting to peak and we are seeing both Flu A and Flu B

With most respiratory illness the most vulnerable are the very young and the elderly. Take precautions. Wash hands. Do not share drinks. Avoid crowded places. Do not take small children to gyms. Do not visit if you have cough or cold symptoms, even if you are “on antibiotics”. Be considerate of others.

Summer Colds

Pegasus or Vitamin K – Know your Facts

Pegasus - The Flying Horse of Greek Mythology

Pegasus – The Flying Horse of Greek Mythology

Myths about the vitamin K shot

Why are some parents refusing the vitamin K shot for their infants? Well, like parents who refuse to vaccinate their children against measles and other infectious diseases, parents who refuse the vitamin K shot are usually basing their decision on misinformation. Often this information is spread via the Internet and propounded by the same small factions of people that urge parents to avoid or delay childhood vaccines. The rumors surrounding the vitamin K shot, like anti-vaccine rumors, are not based in science or medicine but are the result of fear-mongering.
For instance, one myth is that a preservative in the vitamin K shot can cause childhood leukemia. Scientific studies, however, disprove this theory and the American Academy of Pediatrics, after reviewing various studies on this issue, has concluded that there is “no association between the intramuscular administration of vitamin K and childhood leukemia or other cancers.”And, contrary to some reports online, there are no “toxic” or otherwise unsafe ingredients in the routine vitamin K shot.
Another myth is that the vitamin K injection is unnecessary.Some parents believe that an infant will be sufficiently protected if the mother eats plenty of vitamin K prior to delivery and continues to do so while exclusively breastfeeding. The fact is, a mother simply cannot pass sufficient levels of vitamin K to her infant through breastfeeding, even if she eats kale (one of the richest food sources of the vitamin) until she turns a deep leafy green. And while vitamin K does pass through the placenta to the infant, again the amount passed is insufficient to protect the baby.
Other parents believe that they can protect their infant by giving an oral vitamin K drop, and there are some unscrupulous people who sell these drops online. But the drops are a poor substitute for the intramuscular vitamin K injection, for several reasons. Unlike with the injection, there is no standard regimen or formula for oral vitamin K, so parents using it can’t be assured that their child will be protected adequately, if at all. In addition,the absorption of vitamin K is much less reliablefrom an oral liquid than from the injection; that is, just because the baby swallows it doesn’t guarantee they’re getting the full amount of the vitamin. And moreover, whereas the injection is a one-time, single dose, oral vitamin K must be administered repeatedly over a course of weeks.

Excerted fom the article “Why babies need Vitamin K”, which appeared in Berkley Wellness.