Nutrition for the Pediatric Athlete

Viswanath B. Unnithan, PhD, FACSM and Styliani Goulopoulou, BS

Address Exercise Science Department, Syracuse University, Womens Building, Room 201, 820 Comstock Avenue, Syracuse, NY 13210, USA. E-mail: vbunnith@syr.edu Current Sports Medicine Reports 2004, 3:206211 Current Science Inc. ISSN 1537-890x Copyright 2004 by Current Science Inc.

A paucity of literature exists with regard to research on nutrition for the pediatric athlete. This lack of research makes the development of specific nutritional recommendations for young athletes problematic. This issue is made difficult by the macro- and micronutrient intake required for growth and development in conjunction with that required for sports. Exogenous carbohydrate drinks could be considered for the young athlete engaged in both endurance exercise and high-intensity exercise. Monitoring of the energy intake during resistance training in the pediatric athlete needs to be considered, as there is evidence to suggest that energy deficits may occur. If decrements in exercise performance are noted, then serum ferritin and hemoglobin concentrations should be monitored, as nonanemic iron deficiency is prevalent in the pediatric athlete. The pediatric athlete exercising in the heat is susceptible to voluntary dehydration and evidence exists to suggest that a carbohydrate-electrolyte drink will abolish this phenomenon.

Introduction
Nutrition for the pediatric athlete has to be viewed in the context of the physiologic changes that accompany growth in the child and adolescent athlete. These physiologic changes require an increased amount of energy [1]. The primary objective for those working with pediatric athletes is to integrate sports nutrition into the childs training regimen and to ensure the nutritional needs for growth and development are met. The first part of this review discusses the interactions between nutrition and a childs normal growth and the effects that training may have on growth; the second part concentrates on nutritional requirements for performance.

Nutritional Requirements for the Growing Child

Growth is a process characterized by developmental changes in skeletal and muscular dimensions, body

composition, and maturation of different tissues such as nerves, muscle, and liver [1]. It has been identified that adequate nutrition during childhood can have a profound effect on physical and mental development. Although children start being able to feed themselves independently by the second year of life, they depend on adults to develop dietary habits that meet their nutritional requirements. However, limited data are available with respect to the dietary requirements of children. The changes in somatic characteristics and physiologic systems determine the energy and nutritional needs of children and adolescents. Energy is derived principally from macronutrients such as protein, fat, and carbohydrates. A slow decline in protein requirement relative to body weight from infancy to adolescence has been suggested [2]. The recommendation for adolescent boys aged 15 to 18 years is 0.9g (kg/d), whereas the amount of protein suggested for adolescent girls at the same age is slightly less: 0.8g (kg/d) [2,4]. However, in the European Union and United States the average protein dietary intake in children and adolescents is about two- to threefold higher than the recommendations [4]. Other sources for energy are carbohydrates, dietary fiber, and fat. It has been reported that approximately 75% of children take less than the recommended amount of fiber (eg, vegetables, fruits), which is 0.5g/kg to maximum of 35 g/kg daily [5]. With regard to fat intake, the American Academy of Pediatrics and the American Heart Association recommended that children older than 2 years should derive 30% of their total caloric intake from fat [6,7]. It has also been suggested that at least half of this amount should be derived from plant sources. Lower fat intake may be related to inadequate nutrient intake and poor growth. Minerals such as calcium, phosphorus, and magnesium play a prominent role in forming the mineral skeleton. Bone accounts for 99% of the calcium, 80% of the phosphorus, and 60% of the magnesium [2]. Bone mineral density increases during childhood and adolescence until peak bone mass is reached. It should be highlighted that one quarter of adult bone is accumulated during the 2 years surrounding the peak bone growth velocity. Moreover, previous research has shown a relationship between peak bone mass during adolescence and risk for development of osteoporosis in adulthood [8]. Therefore, it is suggested that adequate amounts of the above-mentioned minerals should be included in the diets of young children and adolescents. Dietary deficiency of phosphorus and magnesium are unlikely in healthy children and adolescents

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because most of the foods they eat contain adequate amounts of these minerals [2]. Calcium deficiency most likely occurs because it has been shown that adolescents in the United States often choose diets with a low calcium content [9]. The dietary recommendations for calcium intake from the 1989 recommended dietary allowances are 800 mg/d for children 1 to 10 years old and 1200 mg/d for individuals aged 11 to 24 years [10]. More recently, the 1994 National Institutes of Health Consensus Panel recommended 800 mg/d calcium intake for children aged 1 to 5 years, 800 to 1200 mg/d for children aged 6 to 10 years, and 1200 to 1500 mg/d for individuals aged 11 to 24 years [11]. Calcium supplementation in children and adolescents has been shown to be beneficial in bone mineral accrual; however, the exact amount of calcium required is not clear [12]. It has been demonstrated that the benefit of calcium supplementation is greater in the appendicular compared with the axial skeleton [13]. Further, calcium supplementation appears to be more beneficial in prepubertal compared with pubertal children [13]. Iron is a component of proteins required for oxygen transport, ATP production, DNA synthesis, and other crucial cellular processes [14]. Hence, childrens and adolescents diets should include adequate amounts of this micronutrient. In contrast, 46% of the worlds 5- to 14-year-old children are anemic [15]. Iron deficiency may significantly influence cognition and be related to other neuropsychologic impairments. During adolescence, the mean hemoglobin (Hb) concentration increases from 130 to 133 g/L in girls and 141 g/L in boys [16]. The increasing Hb concentrations during adolescence require an increase in the mean iron levels during this period. The mean iron requirements for girls is 1.8mg/d or more than double the requirements of preadolescent boys [2]. In addition, the iron requirements for adolescent girls after the onset of menarche are higher compared with those of adolescent boys and prepubertal children. In particular, postmenarcheal girls lose an average of 84 mL of blood per menstrual period, which increases the iron need approximately 0.56 mg/d [16]. It is well recognized that there is a normal variation in the rate of growth among individuals. Hence, energy and nutritional needs are variable in children and adolescents. Basal metabolism, sex, physical activity, body size, and onset of puberty are also significant determinants of the nutritional requirements at this period.

young athletes to reach their genetic growth potential [18]. Young female athletes participating in sports with emphasis on low body weight, such as gymnastics and figure skating, show signs of late sexual maturation [19]. It is not clear whether this is a result of their training or reflects self-selection. Moreover, these girl athletes are shorter and lighter compared with sedentary girls at the same age [20]. Clinical eating disorders and restriction of energy intake are special concerns for this athletic population; however, more research is needed to identify the exact role of self-selection, genetic potential, malnutrition, and intensive training on the small stature and delayed sexual maturation of these athletes. Fogelholm et al. [21] suggested that sport training does not affect anthropometric variables such as height, weight, skin folds, and upper arm muscle girth, biologic maturation, or nutritional status. These findings were in accord with Beunen et al. [22], who found no significant effect of increased physical activity on somatic dimensions including skin folds, age at peak height velocity, and skeletal maturation. The aforementioned studies were conducted in nonelite athletes and therefore they cannot be applied on highly trained athletes.

Nutrition and Performance

The remainder of this article is restricted to nutritional factors that could affect performance. Performance is delimited to three major sporting areas: strength- and flexibility-based sports (gymnastics), endurance sports (running/cycling), and high-intensity intermittent sports (soccer, rugby, basketball).

Carbohydrate and Fat

In order to understand the nutritional consequences of carbohydrate and fat manipulation in the diet of the young athlete it is necessary to understand the biochemistry of exercise of the child and adolescent. Lower levels of muscle phosphofructokinase and a reduced glycolytic potential in children compared with adolescents and adults has been identified [23,24]. Higher citrate-cycle enzyme activity and increased lactate dehydrogenase activity in 11- to 14-yearold girls compared with adult women and men has also been noted [25]. The enzymatic profile described in the preceding paragraph seems to suggest that children are metabolically more suited to using free fatty acids (FFA) as a primary substrate for exercise compared with carbohydrates. Significant increases in free glycerol levels in the blood were noted during prolonged exercise (30120 min) in children compared with adults. Even during moderate to high exercise intensities, higher glycerol levels were noted in children compared with adults. These higher glycerol levels also occurred at an earlier time point during exercise in the children compared with adults [26,27]. FFA uptake has

Influence of Exercise and Diet on a Childs Growth and Development

Energy is required for all the physiologic functions as well as for growth and physical activity. Food of poor nutritional value and restricted energy intake negatively affect growth and biologic maturation, even if other nutrient requirements are met [17]. Intensive training has been found to affect the hormones of the hypothalamicpituitary axis; however, it is not clear if this inhibits the

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also been found to be greater in children compared with adults during prolonged submaximal exercise [28]. It was postulated that the large increases in noradrenaline and greater FFA utilization acted as a protective metabolic mechanism to counteract the initial hypoglycemia noted during prolonged submaximal exercise in children. The primary substrates used by the muscles during exercise are carbohydrate and FFA. The major source of the carbohydrates are from muscle glycogen, blood glucose, or hepatic glycogen stores. Fatty acids are derived from the adipose triglyceride via plasma fatty acids or from the intramuscular triglyceride stores. The relative contribution of these substrates during exercise is intensity dependent, with the proportion of carbohydrate to FFA increasing as exercise intensity increases. In an extensive of review of childrens aerobic training programs by Rowland [29], it was identified that in order to produce the same magnitude of improvement in aerobic fitness, the child athlete requires a relatively high volume of exercise at high intensity, thus placing large demands on the bodys limited endogenous carbohydrate stores [30]. Consequently, recent work has focused upon the efficacy of exogenous carbohydrate on exercise performance in children and adolescents. Timmons et al. [31] demonstrated that boys (9 years of age) oxidized more exogenous carbohydrate than men over a 60-minute exercise period when cycling. Boys also maintained higher relative rates of fat oxidation than men, even when fed exogenous carbohydrate. The implication of these findings was that the boys preferential usage of exogenous carbohydrate may enhance prolonged exercise performance. Similar positive findings were also identified by Riddell et al. [32] on the role of exogenous glucose and fructose drinks during exercise in children and adolescents. It was identified that exogenous glucose and fructoseglucose drinks ingested during 90 minutes of submaximal cycling (55% VO 2max ) by 10- to 14-year-old boys, were oxidized at a similar rate, and contributed to 16% of the total energy provision. The drinks also resulted in sparing endogenous fat and carbohydrate by 17% and 14% respectively. During high-intensity exercise following the 90 minutes of prolonged exercise, the fructose-glucose mixture delayed the time to exhaustion by 40% compared with water and the glucose drink, which delayed exhaustion by 25% compared with water. These findings highlighted the potential importance of glucose and fructose-glucose drinks in maintaining performance even during highintensity exercise.

tion vary widely (0.81.2 g/kg/d). When separate values are established for adolescents, they have been generally in the region of 1 g/kg/d [11]. Bar-Or and Unnithan [34] stated that in nonathletic children an increase from the adult value of 0.8 g/kg/d to 1.2 g/kg/d for boys and girls aged 7 to 10 years, with an increase to 1 g/kg/d for those aged 11 to 14 years. After this stage their recommendations are in line with adult figures. Even in a sport such as gymnastics, it has been demonstrated that the young athletes achieved a dietary protein intake of 1.6 g/kg/d [35]. Consequently, the coach and parent should be made aware of a possible increased protein requirement during periods of rapid growth and intensive training. This issue was highlighted by recent research by Pikosky et al. [36]. These researchers demonstrated that resistance training in 9-year-old children two times per week for 6 weeks resulted in a down-regulation in protein metabolism. That is, an increase in energy expenditure as a result of resistance training and growth was not accommodated for by an increase in energy intake. Consequently, an energy deficit occurred.

Fluid Intake and Composition

In order to understand the importance of fluid intake and drink composition for the pediatric athlete it is necessary to review the thermoregulatory physiology of the child compared with the adult. Children and adolescents generate more metabolic heat with respect to body mass compared with adults, mainly as a consequence of their greater surface area to body mass ratio [37]. Children have a lower sweating rate per sweat gland than adults, even when scaled to body surface area [38,39]. This deficit occurs in spite of the fact that children have a greater number of heat-activated sweat glands per unit skin area [39]. It has also been identified that the sweating threshold is considerably higher in children compared with adults [40]. In addition, higher sodium and chloride concentrations have been identified in sweat in children compared with adults [41] Body core temperature also increases at a higher rate during dehydration in children. Despite these differences in the physiologic responses of the child compared with the adult with respect to thermal stress, the critical issue is whether these characteristics will lead to a decrement in performance for the pediatric athlete. There is no definite answer, but it is clear that in severe climatic heat stress performance is affected. Voluntary dehydration (inadequate fluid intake when fluid is offered ad libitum during exercise in the heat) is commonplace in both adults and children [42]. The physiologic consequences for the pediatric athlete are serious; as at any given level of hypohydration, the core temperature of children rises faster than that of adults. The general guidelines that should be issued to children exercising in the heat should be to drink until the child does not feel thirsty

Protein Intake
There is no evidence to suggest that protein metabolism differs between adults and children [33]. Consequently, the increased need for protein intake by active adolescents is a product of exercise and growth and not the consequence of any deficit in the childs metabolism of protein. The recommended dietary intake (RDI) values for the adult popula-

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plus an additional half glass (100125 mL), for adolescents a full glass extra is recommended. However, in order to implement these guidelines for sporting competitions under climatic heat stress conditions, competition regulations need to be altered for the child athlete. Either, allowing the child to leave the field of play periodically, or, as in the Soccer World Cup of 1994, 1998, and 2002, the positioning of drinking bottles on the perimeter of the field to allow for fluid intake during natural stoppages in play. Carbohydrate (6%)-electrolyte drinks (NaCl) have been demonstrated to produce a slight overhydration in children undergoing prolonged submaximal exercise (90 min of cycling) in the heat; grape-flavored water managed to maintain hydration levels over the same period [43]. The concentration of sodium ions in the extracellular fluid has been identified as the primary stimulus for the replenishment of body fluids. Nose et al. [44] demonstrated that the addition of NaCl to water enhanced volume restoration after dehydration than just water alone. Wilk and Bar-Or [43] also demonstrated that there was a 44.5% increase in drinking volume comparing water and grape flavored water; and an additional 46.5% increase in voluntary drinking on the addition of carbohydrate and NaCl. The study design did not allow the partitioning out of the separate effects of carbohydrate and NaCl, but based upon previous studies [42,44], it would appear that most of the benefit was obtained through the addition of NaCl. Based on these studies it would appear that voluntary dehydration could be reduced by drinking flavored water and abolished by drinking a carbohydrateelectrolyte drink.

compared with nonathletes, irrespective of sex. Values were at or below average for age. There was also a significant correlation between the length of time engaged in a sport and reduction in erythrocyte, PCV, and Hb concentration. There is also increasing evidence that a high prevalence of nonanemic iron deficiency does exist in young athletes [50]. High-volume endurance training brought about a significant decrease in serum ferritin as well as iron stores in a group of highly trained swimmers (boys, 1012 years) compared with control subjects. General guidelines for the pediatric athlete are to encourage eating poultry, lean red meat, iron-enriched breakfast cereals, and green vegetables.

Conclusions
Based on the limited research data that exist in the area of nutrition for the pediatric athlete, the following conclusions can be drawn: 1) it appears that exogenous carbohydrate administration to children during prolonged submaximal exercise may enhance performance; more research is needed with respect to the efficacy of exogenous carbohydrate intake in sport-specific situations (cycling and running events); 2) fructose-glucose and glucose mixtures may have the capacity to delay fatigue during high-intensity exercise and short-term exercise; more work is required to see if these findings are applicable in sports such as soccer, basketball, and rugby, which are considered to be high-intensity, intermittent activities; 3) coaches and parents need to be aware of the potential energy deficits that may occur in children engaged in resistance training and therefore need to consider increasing the energy intake accordingly; 4) if performance decrements are noted in the pediatric athlete, particularly those engaged in endurance events, serum ferritin and hemoglobin levels are probably worth checking; this evaluation is warranted in light of the evidence that suggests that nonanemic iron deficiency can exist in these young athletic populations; and 5) voluntary dehydration, a problem for the pediatric athlete exercising in the heat, can be abolished by the administration of a carbohydrate-electrolyte drink during exercise.

Micronutrients
Vitamin and mineral supplements are not really required by the pediatric athlete. Any additional demand for these nutrients as a result of training should be met if the energy intake is sufficient to meet the additional energy expenditure incurred in training and competition. Iron is a micronutrient associated with possible deficits in children and adolescents. Limited evidence of anemia in athletic children and adolescents has been demonstrated [4547]. Some evidence exists of gastrointestinal bleeding in cross-country runners with iron deficiency [48]. It is unlikely that nonanemic iron deficiency will have a significant effect upon athletic performance. In girls with low ferritin and hemoglobin (12 g/dL) levels, performance could be impaired by true mild anemia. If a decline in performance is noted then serum ferritin and hemoglobin are worth assessing. A recent study by Boyadijev and Tralov [49] found lower erythrocyte count, packed cell volume (PCV), and Hb concentrations in untrained and trained girls compared with boys. A total of 876 highly trained athletes (age 14.5 years) from a range of sports were evaluated (swimming, rowing, wrestling, weight lifting, team sports). Erythrocyte, PCV, and Hb were all lower in athletes

References and Recommended Reading

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