Pediatric Primary Care Case Studies (38 page)

Family History

Her maternal grandmother has diabetes and high blood pressure; both paternal grandparents have high blood pressure. Her maternal grandfather died last year of a heart attack (age 58). “I think my Mom has high cholesterol—she is always on a diet.” Father has high blood pressure. A younger sister has asthma, for which she uses an inhaler. She thinks her 20-year-old sister is “OK.”

Nutrition

You ask Nikola about her nutritional habits:

   
Do you skip meals?
“I don’t usually eat breakfast; I eat lunch at school.” Dinner is usually at home or “I grab a snack if there is a track meet.”

   
What do you eat during a typical day?
Breakfast: glass of orange juice; lunch: salad and candy bar; dinner: hamburger and milkshake or salad if she eats out or meat/vegetable/potato at home; snacks: candy bar or power bar. Lots of water or sports drink if running.

   
Who prepares the meals at your house?
“My Mom or Dad usually. We sometimes just go out for a hamburger or pizza on weekends.”

   
As a follow-up to the above question, you ask, “Do you ever cause yourself to throw up or do you take laxatives?
“No, I’d never do that.”
Have you lost weight over the last year or two?
“Yes, about 5 pounds, after I broke up with my boyfriend and started running more to forget.”

Based on the information provided, what else do you need to consider?

From the history and answers gleaned from Nikola up to this point, there are further questions you need answered before you could reasonably be expected to clear her for sports participation.

•   What was the nature and diagnosis of the head injury after the MVA? Did she exhibit any postconcussive syndrome symptoms? Would running place her at further risk of neurological trauma?

•   Does this young lady exhibit risks for the female athlete triad?

Previous Head Trauma

Postconcussive syndrome is a side effect of a minor head injury. The incidence is quite variable, depending upon the definition—29% to 90% (Legome, Alt, & Wu, 2006). Most literature defines this syndrome as comprising the continuation of at least three of the following signs: headache, dizziness, fatigue, irritability, impaired memory and concentration, insomnia, and sensitivity to noise and light. The definition of the syndrome is based upon the onset and duration of symptoms and varies across the literature. It can be defined as occurring within a week of the injury with a duration of a few weeks to 6 months (Legome et al.).

A repeat concussion is often progressively more serious, especially if it occurs before the neurological symptoms from the prior head injury have completely resolved (referred to as
second-impact syndrome)
. The sequelae of the second impact—even as minor as a blow to the chest or back—can cause massive brain swelling and herniation; mortality can approach 50% (Cantu, 2003; Stevenson & Adelson, 2003).

Approximately 300,000 second impact or concussion injuries occur annually in the United States from sports or recreational-related activities (Brain Injury Association, 2004). A participant in an organized sport is six times more likely to suffer such trauma than someone performing a recreational sports activity (Browne & Lam, 2006).

Given that Nikola’s chosen sport is running, a noncontact sport, you can be reasonably assured that she is less likely to suffer another head injury as a consequence of participating in her organized sport. However, had she chosen a contact or collision sport (e.g., soccer) your advice might be different pending further information regarding the nature of her head injury and return-to-play guidelines. (See
Table 10-3
.)

You need to know the following to complete Nikola’s history regarding her head injury (send for her medical records from the hospital and physician who saw her afterwards):

•   Did she suffer from a Grade 1, 2, or 3 concussion? (The definition is based on a recognized set of criteria such as length of loss of consciousness, mental status [impaired orientation, memory, concentration, or delayed information or reaction time], and duration of mental changes.)

•   How long did she exhibit headaches or cranial nerve symptoms after the injury (dizziness, vertigo, nausea, tinnitus, blurry vision, hearing loss, diplopia, diminished sense of taste and smell, sensitivity to light and noise)?

•   Did she exhibit anxiety, irritability, depression, sleep disturbance, change in appetite, decreased libido, fatigue, or personality changes?

•   If she exhibited cognitive changes, for how long after her injury were they experienced?

Female Athlete Triad

Sudden death, one sports-related problem, is less likely to occur in females, but they are more at risk of other conditions. Their risks are altered due to environmental, anatomic, hormonal, biomechanical, and neuromuscular factors (Blosser, 2009). One such condition is referred to as the
female athlete triad
, which is composed of a progressive set of three interrelated conditions. Anorexia (or disordered eating), amenorrhea (including oligomenorrhea), and osteopenia/osteoporosis occur along a continuum rather than in unison. The existence of one of these symptoms, therefore, should serve as a red flag during the PPE. Females engaged in sports where leanness and/or endurance are particularly advantageous are more prone to this disorder (e.g., gymnasts, ballerinas, swimmers and divers, figure skaters, distance runners, and cross-country skiers) (American Academy of Pediatrics [AAP], 2002). Additionally, female runners, cheerleaders, and gymnasts (i.e., those in high impact sports) are at greater risk of suffering a stress fracture than males (Loud et al., 2005). Although the fracture can be an isolated event due to the nature of the exercise itself, footwear, or musculoskeletal factors, it can also be due to osteopenia, osteoporosis, menstrual dysfunction, poor nutrition, or an eating disorder. Common anatomical areas for stress fractures include the foot, tibia, fibula, femur, and pelvis.

The incidence of amenorrhea in athletes can be as high as 66%, depending on the sport. The amenorrhea may be primary (delayed menarche past 16 years), secondary (no menses for 3–6 months after regular menses has been established), or oligomenorrhea (cycle length greater than 35 days but less than 3 months). None of these is a normal response to exercise, and caloric intake will need to be increased and/or exercise will need to be decreased in order to return to a normal body fat-to-lean ratio (AAP, 2002; Griffin et al., 2003).
Serum gonadotropin concentrations are reduced due to reduced hypothalamic pulsatile release of gonadotropin-releasing factor.

Nutritional deficits in an active female athlete can result in an imbalance when energy (caloric) expenditure exceeds energy (caloric) intake. Nutritional intake must meet both growth and activity needs. The adolescent is growing at a rate second only to that of infancy. Disordered eating, such as binging and purging, or the use of laxatives, diuretics, and diet pills for weight control can result in the same energy deficit. The normal hypothalamic-pituitary-ovarian axis necessary for normal menstruation is surmised to be compromised by the caloric input-output imbalance (Griffin et al., 2003).

Osteopenia (with resulting weakened bones) can be a result of the amenorrhea that is in turn due to inadequate body fat and the resultant hypoestrogenemic state. Inadequate bone formation results. Recovery from this state is slow, and whether it is entirely reversible is unclear. Early intervention is crucial because adult bone mineral density is largely determined by the status of bone mass during adolescence and young adulthood (Davidson, 2003; Griffin et al., 2003). Thus, failing to achieve adequate bone mass during this crucial time in life increases the risk of osteoporosis and fractures as an adult. Changes in weight, height, and body mass index (BMI) are good clues to changes in bone mineral density.

In lieu of an eating disorder, hypothalamic amenorrheic female athletes appear fit, their estimated ideal body weight is more than 85%, and their resting pulse is 40–60 beats/minute (Hergenroeder & Chorley, 2004). Early identification, such as that afforded by the PPE, is imperative so preventive interventions can be instituted. This will ensure that the female may be able to return to a high performance level and enjoy good health in the future.

Fractures or Other Musculoskeletal Disorders in the Female Athlete

As stated earlier, an array of factors can lead to stress fractures. When there is an imbalance between bone resorption and bone deposition, the bone may not be physiologically capable of holding up under repetitive loads. The PPE affords the opportunity to explore the underlying risk factors that contribute (or contributed) to the fracture, conduct a pertinent examination, and implement strategies to prevent recurrence.