CLINICAL REPORT Guidance for the Clinician in Rendering Pediatric Care

Resistance Training for Childrenand AdolescentsPaul R. Stricker, MD, FAAP,a Avery D. Faigenbaum, EdD, FACSM, FNSCA,b Teri M. McCambridge, MD, FAAP,c COUNCIL ON SPORTSMEDICINE AND FITNESS

abstractResistance training is becoming more important as an integral part ofcomprehensive sport training regimens, school physical education classes,and after-school fitness programs. The increasing number of youth whoare involved in sport activities, coupled with the health problems of inactivityand being overweight, have resulted in increased interest in resistancetraining. Secular declines in measures of muscular fitness in modern-dayyouth highlight the need for participation in youth resistance trainingfor nonathletes as well as athletes. Parents often ask pediatricians to offeradvice regarding the safety, benefits, and implementation of an effectiveresistance-training program. This report is a revision of the 2008 AmericanAcademy of Pediatrics policy statement and reviews current information andresearch on the benefits and risks of resistance training for children andadolescents.

KEY POINTS

1. Positive outcomes of improved strength in youth continue tobe acknowledged, including improvements in health, fitness,rehabilitation of injuries, injury reduction, and physical literacy.

2. Resistance training is not limited to lifting weights but includes a widearray of body weight movements that can be implemented at youngages to improve declining measures of muscular fitness among childrenand adolescents.

3. Scientific research supports a wide acceptance that children andadolescents can gain strength with resistance training with low injuryrates if the activities are performed with an emphasis on propertechnique and are well supervised.

4. Gains in childhood strength are primarily attributed to theneurologic mechanism of increases in motor neuron recruitment,allowing for increases in strength without resultant musclehypertrophy.

aDepartment of Orthopedics, Pediatric & Adolescent Sports Medicine,Scripps Clinic, San Diego, California; bDepartment of Health andExercise Science, The College of New Jersey, Ewing, New Jersey; andcDepartment of Orthopedics, University of Maryland, College Park,Maryland

Drs Stricker, Faigenbaum, and McCambridge served as authors of themanuscript with substantial input into the content and revision; andall authors approved the final manuscript as submitted.

Clinical reports from the American Academy of Pediatrics benefit fromexpertise and resources of liaisons and internal (AAP) and externalreviewers. However, clinical reports from the American Academy ofPediatrics may not reflect the views of the liaisons or theorganizations or government agencies that they represent.

The guidance in this report does not indicate an exclusive course oftreatment or serve as a standard of medical care. Variations, takinginto account individual circumstances, may be appropriate.

All clinical reports from the American Academy of Pediatricsautomatically expire 5 years after publication unless reaffirmed,revised, or retired at or before that time.

This document is copyrighted and is property of the AmericanAcademy of Pediatrics and its Board of Directors. All authors have filedconflict of interest statements with the American Academy ofPediatrics. Any conflicts have been resolved through a processapproved by the Board of Directors. The American Academy ofPediatrics has neither solicited nor accepted any commercialinvolvement in the development of the content of this publication.

DOI: https://doi.org/10.1542/peds.2020-1011

Address correspondence to Paul R. Stricker, MD, FAAP. E-mail: drpaul@drpaulstricker.com

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2020 by the American Academy of Pediatrics

To cite: Stricker PR, Faigenbaum AD, McCambridge TM, AAPCOUNCIL ON SPORTS MEDICINE AND FITNESS. Resistance Trainingfor Children and Adolescents. Pediatrics. 2020;145(6):e20201011

PEDIATRICS Volume 145, number 6, June 2020:e20201011 FROM THE AMERICAN ACADEMY OF PEDIATRICS by guest on June 6, 2020www.aappublications.org/newsDownloaded from

5. It is important to incorporateresistance training into physicaleducation classes and youth sportprograms to increase muscularstrength, reduce the risk ofoveruse injuries, and spark anongoing interest in this type ofexercise.

6. Certain health situations requireconsultation with a medicalprofessional before startinga program of resistance training.

BACKGROUND

Resistance training and strengthtraining are synonymous terms usedto denote a component of sport andexercise training that is designed toenhance muscular strength, muscularpower, and local muscular endurancefor general exercise or competitivesports. Resistance training isa specialized method of conditioningthat involves the use of differentmodes of training with a wide rangeof resistive loads, from body weightto barbells. Resistance-trainingprograms may include the use of freeweights (barbells and dumbbells),weight machines, medicine balls,

kettlebells, elastic tubing, ora person’s own body weight toprovide the resistance needed toincrease strength.

Along with the extremes of inactivityand/or being overweight and theevolution of youth sports into moreintense training at younger ages,there is also a change in thelandscape of “strength” amongchildren and adolescents. Evidence ofdecreasing measures of muscularfitness in youth over the years addsimportance for involving youth insome form of resistance exerciseregardless of whether they areinvolved in sports.1–3 On the otherhand, some adolescents areincreasingly using resistance trainingin pursuit of muscularity withouteven being involved in sports.4 Thetype, amount, and frequency ofresistance exercises are dictated bythe specific and unique goals of thesport and training program as well asthe individual child’s resistancetraining skill competency (RTSC)and accumulated time of formalresistance training (also referred toas “training age”). Table 1 defines an

alphabetical list of common termsused in resistance training.

RESISTANCE-TRAINING BENEFITS

Performance Benefits

The many benefits of resistancetraining have been increasinglydocumented in the pediatric sportsarena. Although building strength isoften a primary goal, the positivesequelae of strength gains in youthcontinue to be recognized, includingimprovements in motor skillperformance, gains in speed andpower, developing physical literacy,reducing the risk of injury, and injuryrehabilitation. Children and youth areentering competitive sports atyounger ages, and their trainingprograms are becoming morecomplex and can involve the use ofprivate coaching, personal trainers,and sports psychologists in additionto their routine coaches and teams.Possessing adequate strength to keepup with these increased demands onthe body is valuable to help reducethe risk of injury and optimize gainsin performance.

TABLE 1 Definitions

Term Definition

Bodybuilding Lifting weights with the specific goal of increasing muscle size, symmetry, and definition with the possible goal of enteringcompetitive events that are judged

Concentric muscle action The muscle shortens during contraction (ie, lifting phase of bicep curl)Core strengthening Focusing a strength-building program on the muscles that stabilize the trunk and pelvis of the body; this training emphasizes

strengthening the abdominal, low back, and gluteal muscles as well as flexibility of muscular attachments to the pelvis, suchas the quadriceps and hamstring muscles

Eccentric muscle action The muscle lengthens during contraction (ie, lowering phase of bicep curl)Integrative neuromusculartraining

Multimodal exercise program using different types of resistance training to target deficits in strength and motor control byimproving both health- and skill-related components of physical fitness

Isokinetic muscle action This exercise requires special equipment that maintains a fixed speed of muscle contraction throughout the range of motionMuscular fitness A global term that includes muscular strength, muscular power, and local muscular endurancePhysical literacy Moving with confidence and competence in various activities and environments to benefit overall healthPlyometric exercises Repeated, rapid, eccentric, and concentric muscle actions, such as side-to-side hops or squat jumpsPowerlifting A competitive sport that involves maximum lifting ability; powerlifting includes the dead lift, back squat, and bench pressPrehabilitation Strength, flexibility, and functional training aimed at preventing injuries before they happen or reducing the risk of a recurrent

injuryRepetition (rep) One complete movement of an exercise that typically involves lifting and lowering a loadRepetition maximum (RM) The maximum amount of weight that can be lifted with proper exercise technique using a given resistance; a 1 RM is the

maximum resistance that can be used for 1 complete repetition of an exercise, whereas a 10 RM is the maximum resistancethat can be used for 10 complete repetitions of an exercise

Set A group of repetitions performed continuouslyWeightlifting A sport that involves the performance of the snatch and clean-and-jerk exercises in competitionWeightlifting training The use of weightlifting exercises, movements, and derivatives of these exercises incorporated into a training program

2 FROM THE AMERICAN ACADEMY OF PEDIATRICS by guest on June 6, 2020www.aappublications.org/newsDownloaded from

Health Benefits

Healthy lifestyles incorporate regularexercise that provides a balance ofactivities, including participating instrength-building programs. Inaddition to increasing muscularstrength, muscular power, and localmuscular endurance, resistancetraining has been shown to producemany health benefits, includingimprovements in cardiovascularfitness, body composition, bonemineral density, blood lipidprofiles, insulin sensitivity in youthwho are overweight, increasedresistance to injury, and mentalhealth.5–14

Programs involving resistancetraining provide positive options toengage children and adolescents withoverweight or obesity in physicalactivity and may be more likely tocreate a positive and successfulexperience for these participants,who may have lower levels ofphysical fitness, poor exercisecompliance, and reduced tolerancefor aerobic training.15–17 Evidencedoes show that participation ina resistance-training program helpsincrease daily levels of spontaneousactivity in school-aged boys,18,19

which suggests that resistancetraining may be a good place to startwhen trying to get inactive kids to bemore active. Progressing intoa combined program of resistanceand aerobic training may generateadded benefit because combinedprograms have shown favorableeffects on the reduction of total bodyfat in youth.20–22

Additional Benefits

After years of research, it is nowaccepted that children andadolescents can increase strengthwith low injury rates if resistancetraining is well supervised with anemphasis on correct technique. Earlystudies successfully demonstratedsignificant strength gains in childrenand a lack of injury with propertechnique and supervision.5,7,12,23

With a preponderance of studiesshowing positive gains from youthresistance training, perspectives areshifting regarding integratingresistance training into physicaleducation, youth fitness, and injury-reduction programs.

Previous concerns regardingresistance training focused on whatwould happen if a child lifts weights,but more recent focus has turnedtoward what will happen if a childdoes not lift weights, especially inlight of the secular declines inmeasures of muscular fitness over theyears. Targeting strength deficits andbuilding strength reserves willcontinue to be a valuable concept toaddress.24,25 The available researchsupports resistance training in youthwith a new perspective of acquiringand maintaining high strengthreserves to enhance performanceacross a wide range of general andspecific skills while reducing injuryrisk. There is a shift from the primaryconcern of injuries associated withresistance training to the concern ofinjury and other adverse eventsbecause of a lack of adequate strengthto keep up with trainingdemands.14,26,27

Resistance training is applicable tovirtually all children and adolescentsfor contributions to muscular fitness,resistance to injury, and improvedperformance. Enhancing muscularstrength is an important concept toembrace fully beyond the associationwith only lifting progressively heavierweights. This clarification mayencourage girls and boys to engage inyear-round resistance training toincrease their strength reserveswithout fear of getting too muscularor impairing sports performance.

Numerous studies have shown thatchildren and adolescents can gainstrength with resistance-trainingprograms involving technique-driven progression along withqualified supervision andinstruction.5,7,12,23,28–30 Adequate

supervision may be variabledepending on the goals of theresistance-training program, RTSC ofthe participants, and experience ofthe teacher, instructor, or coach. Anexperienced professional may be ableto effectively guide a larger number ofyouth, whereas more individualizedinstruction may be appropriate formore advanced-level techniques.There are many different variablesthat contribute to a well-designedyouth resistance-training program,including quality of instruction,training environment, trainingfrequency, training age, type ofresistance used, intensity of effort,number of sets and repetitions, restinterval between sets and exercises,and duration of training.26

Training and Detraining

Recent studies suggest thatresistance-training programs lasting.23 weeks are most effective inattaining maximal strength gains.30

Strength gains occur with differenttypes of resistance training fora minimum duration of 8 weeks witha frequency of 2 to 3 times a week.In general, detraining effects canoccur after 8 to 12 weeks withoutresistance training,5,7,11,15,31,32 butdetraining is a more complex processin youth because of developmentalimprovements in performance, whichallows some skills to be retainedbetter than others.32 Children recovermore quickly than adults fromresistance-training fatigue; therefore,experts recommend 1 minute of restbetween sets for beginners,increasing to 2 to 3 minutes of rest asthe intensity of training increases(ie, incorporation of weightliftingmovements or plyometricexercises).33 Training exercisesinvolving the core (abdominals, lowback, and gluteal muscles) arefoundationally important forsports participation and canprovide benefit for sport-specificskill acquisition and posturalcontrol.7,34,35

PEDIATRICS Volume 145, number 6, June 2020 3 by guest on June 6, 2020www.aappublications.org/newsDownloaded from

One-Repetition Maximum

The one-repetition maximum (1 RM)(see Table 1 for definition) testcan be administered by qualifiedprofessionals to assess maximalstrength, determine an appropriateresistance-training intensity, andevaluate the effectiveness ofa resistance-training program.36

Previous American Academy ofPediatrics (AAP) policy statementshave not recommended 1 RM testingin skeletally immature individuals.However, 1 RM testing that isproperly administered has beenfound to be a valid and reliablemeasure of strength and power inchildren and adolescents.36,37

Although 1 RM testing is used inpediatric research settings and youthsport facilities, alternative measures(handgrip strength, long jump, andvertical jump) correlate with 1 RMstrength and may be used to evaluatemuscular fitness in youth.38 Researchindicates that 1 RM testing in childrenand adolescents can be safe andefficacious when established testingprotocols are followed by qualifiedprofessionals.36,37,39,40

Mechanisms of Strength Gains

Proper resistance training in childrencan enhance strength withoutresultant muscle hypertrophy. Thesestrength gains are attributedprimarily to a neurologic mechanismwhereby training increases thenumber of motor neurons that are“recruited” to fire with each musclecontraction.41,42 This mechanismaccounts for the increase in strengthin populations with low androgenconcentrations, including girls andpreadolescent boys. In contrast,resistance training during and afterpuberty augments muscle growth byactual muscle hypertrophy.11 Earlystudies regarding resistance traininginvolved nonathletic children, but anincreasing number of studies arebeing conducted with competitiveyoung athletes.43,44 Further researchis needed in the area of long-term

strength improvements withresistance training programs in youngathletes and the effect on theneurologic mechanism of motor unitrecruitment.

Performance Enhancement andOther Uses of Resistance Training

Increases in strength with resistanceprograms have shown improvementin some performance measures, suchas vertical jump, countermovementjumps, and sprint time6,45–47 as wellas improved maximal oxygen uptakewith combined resistance and aerobictraining programs.48 Resistancetraining combined with aerobictraining does not appear to impairstrength gains in youth and may bemore beneficial than single-modetraining.32,49 Translation of thoseimprovements to overall athleticperformance on the field or court maybe more difficult because so manyvariables are involved with actualperformance, making it challenging toseparate the contribution fromresistance training alone. However,positive results in the area ofperformance measures, along withother aspects of sport, such as injuryrehabilitation and injury reduction,make resistance training a valuablepiece of the training landscape andfoundational to long-term athleticdevelopment.50,51

Prehabilitation

Preventive exercise (prehabilitation)uses resistance training to addressand focus on joints that arecommonly at risk for overuse injuries(ie, enhancing rotator cuff andscapular stabilization strengthpreventively to reduce shoulderinjury in athletes who are involved inoverhead sports, such as baseball,softball, tennis, volleyball, swimming,and water polo). Research inadolescent athletes has shownresistance training to contribute todecreased injuries.5–7,14,52,53 Injuryprevention programs may havegreater effectiveness when startedbefore the period of altered

biomechanics that increase injuryrisk.54–56

Various prehabilitation studies arefinding positive results in thereduction of anterior cruciateligament injuries, especially whenresistance training exercises arecombined with plyometricexercises.5–7,45,52,57 Plyometrictraining involves the use of rapidconcentric and eccentric muscleactions to enhance muscle strengthand power in a relatively shortamount of time, such as squat jumps.Plyometric exercises may benefitperformance58–60 and reduce the riskof injury. When combined withproprioceptive training (ie, balanceexercises), these programs have alsobeen shown to be beneficial inrehabilitation and reduction ofcertain injuries, such as anklesprains.61

RESISTANCE TRAINING RISKS

Injury rates in youth resistancetraining settings that adhere toqualified supervision and propertechnique are lower than thoseoccurring in other sports or generalrecess play at school.4 On the basis ofyears of research in this area, there isless concern for injury fromsupervised, well-designed, andtechnique-driven resistance trainingand more concern for injuries thatoccur because of poor supervision, aninappropriate progression of trainingloads, or low strength reserves inyouth who are not prepared for thedemands of sports practice andcompetition.

Overtraining Risks

Resistance training has more ofa place in injury reduction than in thecause of injury. However, prolongedtraining with heavy loads andresistance training without adequaterest and recovery between sessionshave been correlated with increasedinjuries and illness,62–64 thusrequiring similar attention as withother sources of overtraining and

4 FROM THE AMERICAN ACADEMY OF PEDIATRICS by guest on June 6, 2020www.aappublications.org/newsDownloaded from

sensible incorporation into the yearlytraining schedule. It is important toaccount for time spent in resistancetraining as part of total trainingtime to reduce the risk of overuseinjuries. Resistance training can beincorporated into a year-round planthat varies in volume and intensitydepending on the sport season (eg,preseason, in season, or off season).

The AAP recommends rest fromcompetitive athletics, sport-specifictraining, and practice by taking atleast 1 to 2 days off per week to allowfor physical and psychologicalrecovery.65 Adequate fluid and caloricintake is necessary to provide the fuelto exercise, compete, recover, andgrow.66,67 Athletes participating inhigh levels of training volumewho are underrecovered andundernourished are at risk forovertraining, injury, and illness.68,69

Skeletal Risks

Appropriately designed resistancetraining programs have no apparentnegative effect on linear growth,physeal health, or the cardiovascularsystem.7,22 Explosive contractions ofthe muscle-tendon attachment atapophyseal areas during active play,sports, or lifting weights may increasethe risk of avulsion fracture untilcloser to skeletal maturity.70,71

Resistance training safety is enhancedwhen teachers, coaches, andinstructors ensure a safetraining environment and usedevelopmentally appropriateteaching strategies, focus onenhancing RTSC, and have anappropriate instructor/participantratio. This ratio can vary on the basisof the expertise of the instructor,program design, and training ageand RTSC of participants.

National Electronic InjurySurveillance System

Results of the US Consumer ProductSafety Commission’s NationalElectronic Injury Surveillance System(NEISS) have raised concerns about

injuries from the use of weights andresistance training. The NEISS collectsdata on injuries related to strengthtraining equipment but does notprovide information on supervision,program design, or trainingexperience. This system warrantsmentioning in this report to reduceconflicting information among thegeneral public who read NEISSinformation. Careful interpretation ofNEISS data is needed because mostinjuries reported from resistancetraining occur on home gymequipment with unsafe behavior inunsupervised settings.72 These dataare in stark contrast to data fromwell-designed studies withappropriate supervision andtechnique, making education ofparents necessary to reduceconfusion about the risks associatedwith resistance training in the youthpopulation.12,73–75

NEISS data suggest that musclestrains account for many of thereported injuries, and areas that aremost commonly injured are the hand,low back, and upper trunk; recentNEISS data also suggest that handinjuries are particularly common inchildren ,12 years old.76,77 NEISSdata neither specify the cause of theinjury (ie, attempting to lift a heavyload with poor technique) norseparate recreational fromcompetitive weightlifting orpowerlifting injuries, but the datasupport the need for qualifiedsupervision and equipment that areappropriate for the size and skill levelof youth involved in resistancetraining.

Various intense metabolicconditioning programs incorporatedifferent types of resistance training,running intervals, and repetitive bodyweight exercises, such as plyometrics,into training sessions. This type ofhigh-intensity circuit training istypically characterized by theperformance of a maximum numberof repetitions of selected exercises fora predetermined time interval. In

adult metabolic conditioningprograms, the shoulder, knee, and lowback are most commonly injured,78

but safety in the pediatric populationis undetermined because of a lack ofcurrent data. As with any type ofresistance training, it is important tohave proper exercise technique,qualified supervision, and adequaterecovery between intense trainingsessions.

Medical Conditions

Certain health situations requirespecial attention before beginninga resistance training regimen.Athletes with poorly controlled,preexisting hypertension requireconsultation with a medicalprofessional because of the risk ofmarked elevation of blood pressureduring resistance training withweights. Using one’s own body weightis an acceptable alternative untila consultation can be obtained.79,80

Consultation with a medicalprofessional regarding resistancetraining is also required for youngathletes with uncontrolled seizuredisorders,81 although resistancetraining has been determined to besafe in children with underlyingseizures that are well controlled onmedication.81,82

Some children and adolescentsmay be disqualified fromparticipation in resistance trainingbecause of certain medical conditions.Counseling against resistancetraining is necessary for youngsterswith hypertrophic cardiomyopathywho are at risk for worseningventricular hypertrophy andrestrictive cardiomyopathy orhemodynamic decompensationsecondary to an acute increase inpulmonary hypertension.83

Resistance training should be avoidedin individuals with pulmonaryhypertension because of a risk ofacute decompensation duringa sudden change in hemodynamicsas well as those with Marfansyndrome.83

PEDIATRICS Volume 145, number 6, June 2020 5 by guest on June 6, 2020www.aappublications.org/newsDownloaded from

Although exercise interventions thatinclude resistance training may bebeneficial for youth with cancer,84

certain chemotherapeutic agentsrequire caution. Youth witha previous history of cancer treatedwith anthracycline chemotherapy areat increased risk for cardiotoxicityand acute congestive heart failureduring resistance training, asevidenced by case reports associatedwith doxorubicin, daunomycin ordaunorubicin, idarubicin, andpossibly mitoxantrone.85

Misconceptions and Evidence

The health supervision visit is a goodopportunity to explore the topic ofresistance training, dispel the mythsassociated with this type of exercise(Table 2), and discuss the importanceof staying physically active andstrong. These visits can allow for theidentification of risk factors forinjury; discussion of family history,medical conditions, medications,previous injuries, as well as traininggoals; motivation for resistancetraining; discussion of experience;and discussion of expectations fromboth the child and parents. It isvaluable for pediatricians to counselfamilies about the multiple health andfitness benefits of resistance training,including improvements in muscularstrength, muscular power, sportsperformance, injury resistance, andlong-term athletic development.

Performance-Enhancing Substances

The AAP strongly opposes the use ofperformance-enhancing substancesand vigorously endorses efforts toeliminate their use among childrenand adolescents.86 Information isavailable for health care providers toprovide regarding the risks andhealth consequences of anabolicsteroids and other performance-enhancing drugs as well as todiscourage youth from consideringtheir use. For instance, the AAP hasa training simulation on addressingthe use of performance-enhancingsubstances (available at www.aap.kognito.com).

Integrative Neuromuscular Training

In this era of sedentary pursuits oftechnology and social media, keepingchildren and adolescents active andoptimally developing motor skills,muscular fitness, and physical literacyis challenging. No longer can it beassumed that children innately knowhow to run, hop, jump, and throw.Integrative neuromuscular training isa multimodal form of training thatuses resistance exercises, dynamicstability, core exercises, andplyometric and agility trainingperformed in short intervals withintermittent periods of rest.26,87

Integrative neuromuscular trainingcan improve muscular fitness inyouth, enhance motor skilldevelopment, improve sports

performance, and decrease sportsinjury risk.12,87

It is difficult to say at what age a childcan begin resistance training becauseof developmental differences. Ifa child is able to begin participating insports activities at 5 years of age,being able to begin some type ofresistance training with body weightmovements at that age is acceptablebecause strength gains can be madein ways other than lifting externalloads. An age range of 5 to 7 years iswhen many children are ofteninvolved in sports participation, andit is reasonable that they can alsobenefit from the strength-buildingprocess with exercises such as frogjumps, bear crawls, crab walks,kangaroo hops, and one-leg hops.88

The one-leg hop is a skill most 5-year-olds should be able to perform,89

although the ability to perform morecomplex movements will beinfluenced by the amount of timeyouth have practiced basic skillsand reinforced desired movementpatterns. The combination ofqualified instruction with technique-driven progression is likely to yieldthe greatest benefits for youth atany age.

Training Age

The more recent concepts of “trainingage” and RTSC can be used in thedesign of a resistance trainingprogram. Training age refers to the

TABLE 2 Misconceptions Versus Evidence

Misconceptions Evidence

A child is unable to increase strength beforepuberty.

Prepubertal children are able to gain strength by an increase in neurologic recruitment of muscle fibers,and gains in strength can be made with low injury rates if resistance training programs are wellsupervised with an emphasis on proper technique.

Young boys and girls may get “muscle bound” ifthey resistance train.

Prepubertal strength gains occur by neurologic mechanisms, and pubertal gains may augment musclegrowth by actual muscle hypertrophy enhanced by pubertal hormones.

Resistance training may decrease aerobicperformance in youth.

Improvements in aerobic performance have been shown with combined aerobic and resistance trainingprograms, and combined aerobic and resistance programs do not appear to impair strength gains inchildren.

Resistance training may stunt growth. Well-designed resistance training programs have not been shown to have a negative effect on physeal(growth plate) health, linear growth, and cardiovascular health in youth.

Children are stronger now than ever before. There is a need to target strength deficits and build strength reserves due to declining measures ofmuscular fitness in modern-day youth.

1 RM testing is unsafe for youth. 1 RM testing may be a safe method for assessing muscular strength in youth provided that qualifiedsupervision is present and appropriate testing guidelines are followed.

6 FROM THE AMERICAN ACADEMY OF PEDIATRICS by guest on June 6, 2020www.aappublications.org/newsDownloaded from

cumulative amount of time spent informalized training, and RTSCincorporates the quantity of weightlifted, the quality of the liftingmovement, and the emotionalmaturity of the athlete.26,90 As theathlete’s RTSC advances, higher loadsmay be used in a technique-drivenprocess, and a gradual progression ofincorporating skills requiring higherdegrees of technical ability may beincluded (ie, more advancedweightlifting movements andplyometric exercises).7

Understanding training age and theimportance of RTSC allows fordevelopmentally appropriate,progressive training rather thanrelying on previous recommendationsbased solely on chronological age.With earlier participation in well-designed and properly supervisedresistance training, a 10-year-old girlmay already have 3 years ofresistance-training experience versusa 14-year-old boy who is a beginnerand has a resistance training age of 0.

Ways and Means of ImprovingStrength

Gains in strength can be acquired viavarious types of resistance trainingmethods and equipment, includingbody weight, free weights, resistancebands, kettlebells, medicine balls, andchild-size machines. Most fitnesscenters use equipment made for adultbodies and greater weightincrements, but child-appropriatemachines are available in some youthcenters across the country.Dumbbells, kettlebells, and medicineballs require good balance controland technique while being small insize, portable, and allowing for sport-specific motions.

The Use of Weightlifting Movements

The competitive sport of weightliftingincludes the snatch and the clean-and-jerk exercises, whereasweightlifting movements includederivatives of these exercises.Research has demonstrated that thistype of weightlifting training is

superior in improvingcountermovement jumps, horizontaljumps, and 5- and 20-m sprints overtraditional resistance training.47,91

Research has demonstrated that iflight loads are used to learn thesecomplex movements, and ongoingquality instruction is available fortechnique-driven progression, thenweightlifting exercises and theirderivatives can be incorporated intoyouth training programs safely.7

Learning how to perform thesemultijoint lifts correctly requiresconsiderable time and coachingexpertise. Performing these multijointmovements in childhood can helpyouth gain competence andconfidence in performing these skills.If weightlifting movements are goingto be incorporated into a youthtraining program, the followingguidelines are to be considered.

� Advance in a gradual fashion,learning the lifts with a woodendowel then progressing to anunloaded, light barbell and finallyto a weighted barbell, focusing onproper form throughout thetechnique-driven progression.These weightlifting movementscan be incorporated into beginnerprograms but will depend on thegoal of the program and quality ofinstruction available.

� Consider training age and RTSClevel, which will vary individuallyon the basis of cumulative trainingand level of instruction.

� Perform under the guidance ofa professional with requisitecoaching certifications, such asa certified strength andconditioning specialist (NationalStrength and ConditioningAssociation), accredited strengthand conditioning coach (UKStrength and ConditioningAssociation), or USA weightliftingcoach (USA Weightlifting).

Competitive bodybuilding is theapplication of resistance trainingprinciples specifically for the

appearance-related purposes ofmaximizing muscle mass, symmetry,and body definition. Endogenousanabolic hormones are necessary forthe increased muscle mass that is theprimary goal of bodybuilding. “Latebloomers” are often tempted to try tobuild muscle mass by increasing theintensity and volume of training;however, there is no substitute for theonset of puberty, and increasedtraining does not hasten thebiological clock. Concerns aboutabnormal eating behaviors, excessivefocus on body image, or use ofanabolic agents and otherperformance-enhancing substanceswarrant careful screening for thesebehaviors in any adolescent whopursues competitive bodybuilding.

Resistance Training Roadmap

Suggestions for youth who areengaged in a resistance trainingprogram are as follows.

� Qualified instructors withappropriate certifications whounderstand youth resistance-training principles and thephysical and psychosocialuniqueness of youth shouldprovide real-time feedback toensure safe and correct movementdevelopment.

� Begin with 1 to 2 sets of 8 to 12repetitions using a low resistancetraining intensity (ie,#60% 1 RM)as proper technique is developed.A low resistance training intensityallows for the completion of 8 to12 repetitions of a variety ofexercises without undue fatigue.

� As RTSC improves and can bedemonstrated consistently, it isreasonable to increase weight in5% to 10% increments and reducethe number of repetitions.

� The program can be progressed to2 to 4 sets of 6 to 12 repetitionswith a low to moderate trainingintensity (#80% 1 RM).

� Young athletes can be introducedto periodic phases of lower

PEDIATRICS Volume 145, number 6, June 2020 7 by guest on June 6, 2020www.aappublications.org/newsDownloaded from

repetition ranges (,6) at a highertraining intensity (.80% 1 RM)provided that RTSC is high.30

� When performing more complex,multijoint exercises, such asweightlifting, the importance ofcompleting all repetitions withproper technique is vital toachieve proper motor controldevelopment. During this type ofresistance training, fewerrepetitions (eg, 1–3) may beproductive to aid in motor controldevelopment.

� Include all muscle groups,including core muscles, ina resistance training program.

� Perform the various exercisesthrough the full range of motionwith proper technique.

� Perform exercises in a particularsequence during training. Ingeneral, work large muscle groupsbefore small muscle groups andcomplex, multijoint exercisesbefore single-joint exercises.

� Achieving strength gains requiresessions to be at least 20 to30 minutes long and performed2 to 3 times per week onnonconsecutive days whilegradually increasing resistancetraining intensity and volume asstrength and RTSC improve.

� Keep the resistance trainingstimulus effective and enjoyableby periodically varying theexercises, sets, and repetitions.

� Use dynamic warm-up exercisesintegrated into the trainingsession followed by cool-downperiods with appropriatestretching techniques.

� Youth resistance trainingprograms should be techniquedriven and consistent with theneeds, abilities, and maturity levelof the participants.

Guidelines have been proposed by theNational Strength and ConditioningAssociation5 and the 2014International Consensus position

statement on youth resistancetraining.7

Resistance training is highlyencouraged as part of a multifacetedapproach to physical literacy, exercise,strength building, fitness, and athleticperformance in youth. It is valuable toemphasize that combining aerobictraining with resistance training alsooffers long-term benefits for generalhealth and fitness. Important factorsconcerning child health are fuelingthe need for resistance training for allyouth. Trends of decreasing muscularfitness in youth and the requirementof strength for competency inmovement skill development areimportant and make it meaningful forfamilies to be aware of the benefits ofintegrating strength-buildingactivities into a well-rounded exerciseprogram for general physical fitness,sports participation, and lifelonghealth and wellbeing. It is alsoimportant for youth who are involvedin resistance training to be able toparticipate in a safe, supportive, andnonabusive environment. Health careproviders, parents, and coaches whoare interested in learning more arereferred to the US Center forSafeSport (www.safesport.org) andthe AAP clinical report on organizedsports.92

RECOMMENDATIONS

The necessity and appropriateness ofa youth resistance training programare determined on the basis of theprogram goals and RTSC ofparticipants. Proper exercisetechnique and qualified supervisionare necessary for youth resistance-training programs to be safe,effective, and enjoyable. Withenthusiastic instruction, constructivefeedback, and program variation,resistance training can becomea lifetime activity. Recommendationsfor a youth resistance trainingprogram are as follows.

1. Obtain consultation witha medical professional before

beginning a resistance trainingprogram in youth withuncontrolled hypertension,uncontrolled seizure disorders,specific cardiovascularconditions, or a history oftreatment with an anthracyclinechemotherapeutic agent.

2. Seek consultation witha pediatric cardiologist forchildren with complex congenitalcardiac diseases for guidance onsafety and possible modificationof participation.

3. Integrate aerobic and resistancetraining along with other skill-related fitness components intodevelopmentally appropriateexercise training (ie, integrativeneuromuscular training) tocreate a comprehensive fitnessprogram.

4. In youth with overweight orobesity, start with basicresistance exercises over a moreaerobically based program tosupport and encouragesuccessful physical activity bothshort- and long-term.

5. Include dynamic warm-upexercises in the training sessionand cool down with less intensestretching.

6. Encourage participants to havean adequate intake of fluids andproper nutrition because bothare important for energy storage,recuperation, and competition.Proper fuel is beneficial for thecaloric demands of exercise,performance, recovery, andgrowth.

7. Assess RTSC and provide real-time feedback on exercisetechnique to minimize risk andmaximize benefit from resistancetraining. This can be achieved bythe following.

� Exercises should beperformed initially with littleor no load until RTSCimproves and propertechnique has been mastered.

8 FROM THE AMERICAN ACADEMY OF PEDIATRICS by guest on June 6, 2020www.aappublications.org/newsDownloaded from

� Incremental loads may thenbe added by using either bodyweight or other forms ofresistance as long as properform can be maintained.

� In youth with more advancedtraining age, higher loads andintensities will be necessaryto increase muscular strengthand power in preparation forsports.30,43,44

� 1 RM testing may beappropriate to develop anindividualized resistancetraining program and monitorprogress.

8. Address all major muscle groupsof the upper and lower bodyalong with the core and includemultijoint activities, such assquats and weightliftingexercises, for a comprehensiveprogram for building muscularstrength and power. Theseexercises may be complementedby adding more focusedexercises to address sport-specific goals.

9. Sensibly incorporate resistancetraining and account for timespent in resistance training aspart of the total training plan toreduce the risk of overuseinjuries. Monitoring time spentresistance training in school-and community-based programsin addition to other typesof training is important toaccount for true total trainingvolume.93

10. Evaluate any symptom of illnessor sign of injury or overuse fromresistance training or sport

participation before allowing theexercise program to resume.

11. Incorporate weightliftingexercises and their derivativesinto an exercise program underthe direction of a qualifiedprofessional. Progress froma wooden dowel to an unloadedbarbell as RTSC improves.

12. Educate athletes about the risksassociated with the use ofperformance-enhancingsubstances and/or drugs andanabolic steroids to discouragethe use of such substances.

13. Enhance resistance trainingsafety by using professionals whoare qualified, trained, and awareof the unique aspects of youthand possess a recognizedstrength and conditioningcertification. Instructor/participant ratio is important anddepends on the experience of theinstructor as well as the trainingage and RTSC of participants.Licensed physical educationteachers and certified fitnessprofessionals with understandingand experience in training youthmay provide safe and effectiveprograms for children andadolescents, and young athletesmay receive qualified instructionfrom their high school coaches orstrength and conditioningspecialists.94

14. Use proper technique andsupervision by a qualifiedprofessional as necessary safetycomponents in any resistancetraining program involvingchildren and adolescents.

LEAD AUTHORS

Paul R. Stricker, MD, FAAPAvery D. Faigenbaum, EdD, FACSM, FNSCATeri M. McCambridge, MD, FAAP

COUNCIL ON SPORTS MEDICINE ANDFITNESS EXECUTIVE COMMITTEE,2017–2018

Cynthia R. LaBella, MD, FAAP, ChairpersonM. Alison Brooks, MD, FAAP, Chairperson-ElectGreg Canty, MD, FAAPAlex B. Diamond, DO, FAAPWilliam Hennrikus, MD, FAAPKelsey Logan, MD, FAAPKody Moffatt, MD, FAAPBlaise A. Nemeth, MD, MS, FAAPK. Brooke Pengel MD, FAAPAndrew R. Peterson MD, MSPH, FAAPPaul R. Stricker, MD, FAAP

LIAISONS

Donald W. Bagnall – National AthleticTrainers AssociationMark E. Halstead, MD, FAAP – AmericanMedical Society for Sports Medicine

CONSULTANTS

Michele LaBotz, MD, FAAPAndrea Stracciolini, MD, FAAP

STAFF

Anjie Emanuel, MPH

ABBREVIATIONS

1 RM: 1-repetition maximumAAP: American Academy of

PediatricsNEISS: National Electronic Injury

Surveillance SystemRTSC: resistance training skill

competency

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

FUNDING: No external funding.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

PEDIATRICS Volume 145, number 6, June 2020 9 by guest on June 6, 2020www.aappublications.org/newsDownloaded from

REFERENCES

1. Laurson KR, Saint-Maurice PF, Welk GJ,Eisenmann JC. Reference curves forfield tests of musculoskeletal fitness inU.S. children and adolescents: the 2012NHANES national youth fitness survey.J Strength Cond Res. 2017;31(8):2075–2082

2. Müllerová D, Langmajerová J, Sedlá�cekP, et al. Dramatic decrease in muscularfitness in the Czech schoolchildren overthe Last 20 years. Cent Eur J PublicHealth. 2015;23(suppl):S9–S13

3. Cohen DD, Voss C, Taylor MJ, DelextratA, Ogunleye AA, Sandercock GR. Ten-yearsecular changes in muscular fitness inEnglish children. Acta Paediatr. 2011;100(10):e175–e177

4. Eisenberg ME, Wall M, Neumark-Sztainer D. Muscle-enhancing behaviorsamong adolescent girls and boys.Pediatrics. 2012;130(6):1019–1026

5. Faigenbaum AD, Kraemer WJ, BlimkieCJ, et al. Youth resistance training:updated position statement paper fromthe National Strength and ConditioningAssociation. J Strength Cond Res. 2009;23(suppl 5):S60–S79

6. Myer GD, Faigenbaum AD, Chu DA, et al.Integrative training for children andadolescents: techniques and practicesfor reducing sports-related injuries andenhancing athletic performance. PhysSportsmed. 2011;39(1):74–84

7. Lloyd RS, Faigenbaum AD, Stone MH,et al. Position statement on youthresistance training: the 2014International Consensus. Br J SportsMed. 2014;48(7):498–505

8. Hind K, Burrows M. Weight-bearingexercise and bone mineral accrual inchildren and adolescents: a review ofcontrolled trials. Bone. 2007;40(1):14–27

9. Wang Q, Alén M, Nicholson P, et al.Weight-bearing, muscle loading andbone mineral accrual in pubertal girls--a 2-year longitudinal study. Bone. 2007;40(5):1196–1202

10. Bernardoni B, Thein-Nissenbaum J, FastJ, et al. A school-based resistanceintervention improves skeletal growthin adolescent females. Osteoporos Int.2014;25(3):1025–1032

11. McCambridge TM, Stricker PR;American Academy of PediatricsCouncil on Sports Medicine and Fitness.Strength training by children andadolescents. Pediatrics. 2008;121(4):835–840

12. Faigenbaum AD, Myer GD. Resistancetraining among young athletes: safety,efficacy and injury prevention effects.Br J Sports Med. 2010;44(1):56–63

13. Ishikawa S, Kim Y, Kang M, Morgan DW.Effects of weight-bearing exercise onbone health in girls: a meta-analysis.Sports Med. 2013;43(9):875–892

14. Lauersen JB, Andersen TE, Andersen LB.Strength training as superior, dose-dependent and safe prevention of acuteand overuse sports injuries:a systematic review, qualitative analysisand meta-analysis. Br J Sports Med.2018;52(24):1557–1563

15. McGuigan MR, Tatasciore M, Newton RU,Pettigrew S. Eight weeks of resistancetraining can significantly alter bodycomposition in children who areoverweight or obese. J Strength CondRes. 2009;23(1):80–85

16. Sothern MS, Loftin JM, Udall JN, et al.Safety, feasibility, and efficacy ofa resistance training program inpreadolescent obese children. AmJ Med Sci. 2000;319(6):370–375

17. Sgro M, McGuigan MR, Pettigrew S,Newton RU. The effect of duration ofresistance training interventions inchildren who are overweight or obese.J Strength Cond Res. 2009;23(4):1263–1270

18. Meinhardt U, Witassek F, Petrò R, Fritz C,Eiholzer U. Strength training andphysical activity in boys: a randomizedtrial. Pediatrics. 2013;132(6):1105–1111

19. Eiholzer U, Meinhardt U, Petrò R,Witassek F, Gutzwiller F, Gasser T. High-intensity training increasesspontaneous physical activity inchildren: a randomized controlledstudy. J Pediatr. 2010;156(2):242–246

20. Alberga AS, Prud’homme D, Kenny GP,et al. Effects of aerobic and resistancetraining on abdominal fat,apolipoproteins and high-sensitivityC-reactive protein in adolescents withobesity: the HEARTY randomized clinicaltrial. Int J Obes. 2015;39(10):1494–1500

21. Jung HC, Jeon S, Lee NH, Kim K, Kang M,Lee S. Effects of exercise interventionon visceral fat in obese children andadolescents. J Sports Med Phys Fitness.2019;59(6):1045–1057

22. Sigal RJ, Alberga AS, Goldfield GS, et al.Effects of aerobic training, resistancetraining, or both on percentage bodyfat and cardiometabolic risk markersin obese adolescents: the healthy eatingaerobic and resistance training inyouth randomized clinical trial. JAMAPediatr. 2014;168(11):1006–1014

23. Malina RM. Weight training in youth-growth, maturation, and safety: anevidence-based review. Clin J SportMed. 2006;16(6):478–487

24. Suchomel TJ, Nimphius S, Stone MH.The importance of muscular strength inathletic performance. Sports Med.2016;46(10):1419–1449

25. Suchomel TJ, Nimphius S, Bellon CR,Stone MH. The importance of muscularstrength: training considerations.Sports Med. 2018;48(4):765–785

26. Faigenbaum AD, Lloyd RS, MacDonald J,Myer GD. Citius, Altius, Fortius:beneficial effects of resistance trainingfor young athletes: narrative review. BrJ Sports Med. 2016;50(1):3–7

27. Fröberg A, Alricsson M, Ahnesjö J.Awareness of currentrecommendations and guidelinesregarding strength training for youth.Int J Adolesc Med Health. 2014;26(4):517–523

28. Moro T, Bianco A, Faigenbaum AD, PaoliA. [Pediatric resistance training:current issues and concerns]. MinervaPediatr. 2014;66(3):217–227

29. Faigenbaum AD, Lloyd RS, Myer GD.Youth resistance training: pastpractices, new perspectives, and futuredirections. Pediatr Exerc Sci. 2013;25(4):591–604

30. Lesinski M, Prieske O, Granacher U.Effects and dose-response relationshipsof resistance training on physicalperformance in youth athletes:a systematic review and meta-analysis.Br J Sports Med. 2016;50(13):781–795

31. Faigenbaum AD, Farrell AC, Fabiano M,et al. Effects of detraining on fitnessperformance in 7-year-old children.

10 FROM THE AMERICAN ACADEMY OF PEDIATRICS by guest on June 6, 2020www.aappublications.org/newsDownloaded from

J Strength Cond Res. 2013;27(2):323–330

32. Santos AP, Marinho DA, Costa AM,Izquierdo M, Marques MC. The effects ofconcurrent resistance and endurancetraining follow a detraining period inelementary school students. J StrengthCond Res. 2012;26(6):1708–1716

33. Faigenbaum AD, Ratamess NA,McFarland J, et al. Effect of rest intervallength on bench press performance inboys, teens, and men. Pediatr Exerc Sci.2008;20(4):457–469

34. Weston M, Hibbs AE, Thompson KG,Spears IR. Isolated core trainingimproves sprint performance innational-level junior swimmers. IntJ Sports Physiol Perform. 2015;10(2):204–210

35. Prieske O, Muehlbauer T, Borde R, et al.Neuromuscular and athleticperformance following core strengthtraining in elite youth soccer: role ofinstability. Scand J Med Sci Sports.2016;26(1):48–56

36. Faigenbaum AD, Milliken LA, WestcottWL. Maximal strength testing in healthychildren. J Strength Cond Res. 2003;17(1):162–166

37. Faigenbaum AD, McFarland JE, HermanRE, et al. Reliability of the one-repetition-maximum power clean testin adolescent athletes. J Strength CondRes. 2012;26(2):432–437

38. Milliken LA, Faigenbaum AD, Loud RL,Westcott WL. Correlates of upper andlower body muscular strength inchildren. J Strength Cond Res. 2008;22(4):1339–1346

39. Castro-Piñero J, Ortega FB, Artero EG,et al. Assessing muscular strength inyouth: usefulness of standing long jumpas a general index of muscular fitness.J Strength Cond Res. 2010;24(7):1810–1817

40. Duhig S. Strength training for the youngathlete. J Aust Strength Cond. 2013;21:5–13

41. Ramsay JA, Blimkie CJ, Smith K, GarnerS, MacDougall JD, Sale DG. Strengthtraining effects in prepubescent boys.Med Sci Sports Exerc. 1990;22(5):605–614

42. Ozmun JC, Mikesky AE, Surburg PR.Neuromuscular adaptations following

prepubescent strength training. MedSci Sports Exerc. 1994;26(4):510–514

43. Granacher U, Lesinski M, Büsch D, et al.Effects of resistance training in youthathletes on muscular fitness andathletic performance: a conceptualmodel for long-term athletedevelopment. Front Physiol. 2016;7:164

44. Behm DG, Young JD, Whitten JHD, et al.Effectiveness of traditional strength vs.power training on muscle strength,power and speed with youth:a systematic review and meta-analysis.Front Physiol. 2017;8:423

45. Noyes FR, Barber-Westin SD, TutaloSmith ST, Campbell T. A trainingprogram to improve neuromuscularand performance indices in female highschool soccer players. J Strength CondRes. 2013;27(2):340–351

46. de Hoyo M, Pozzo M, Sañudo B, et al.Effects of a 10-week in-seasoneccentric-overload training program onmuscle-injury prevention andperformance in junior elite soccerplayers. Int J Sports Physiol Perform.2015;10(1):46–52

47. Chaouachi A, Hammami R, Kaabi S,Chamari K, Drinkwater EJ, Behm DG.Olympic weightlifting and plyometrictraining with children provides similaror greater performance improvementsthan traditional resistance training.J Strength Cond Res. 2014;28(6):1483–1496

48. Marta C, Marinho DA, Barbosa TM,Izquierdo M, Marques MC. Effects ofconcurrent training on explosivestrength and VO(2max) in prepubescentchildren. Int J Sports Med. 2013;34(10):888–896

49. Gäbler M, Prieske O, Hortobágyi T,Granacher U. The effects of concurrentstrength and endurance trainingon physical fitness and athleticperformance in youth: a systematicreview and meta-analysis. Front Physiol.2018;9:1057

50. Lloyd RS, Cronin JB, Faigenbaum AD,et al. National Strength andConditioning Association positionstatement on long-term athleticdevelopment. J Strength Cond Res.2016;30(6):1491–1509

51. Bergeron MF, Mountjoy M, Armstrong N,et al. International Olympic Committee

consensus statement on youth athleticdevelopment. Br J Sports Med. 2015;49(13):843–851

52. Sugimoto D, Myer GD, Foss KD, HewettTE. Specific exercise effects ofpreventive neuromuscular trainingintervention on anterior cruciateligament injury risk reduction in youngfemales: meta-analysis and subgroupanalysis. Br J Sports Med. 2015;49(5):282–289

53. Foss KDB, Thomas S, Khoury JC, MyerGD, Hewett TE. A school-basedneuromuscular training program andsport-related injury incidence:a prospective randomized controlledclinical trial. J Athl Train. 2018;53(1):20–28

54. Myer GD, Sugimoto D, Thomas S, HewettTE. The influence of age on theeffectiveness of neuromusculartraining to reduce anterior cruciateligament injury in female athletes:a meta-analysis. Am J Sports Med.2013;41(1):203–215

55. Rössler R, Junge A, Bizzini M, et al. Amultinational cluster randomisedcontrolled trial to assess the efficacy of‘111 Kids’: a warm-up programme toprevent injuries in children’s football.Sports Med. 2018;48(6):1493–1504

56. Ryman Augustsson S, Ageberg E.Weaker lower extremity musclestrength predicts traumatic knee injuryin youth female but not male athletes.BMJ Open Sport Exerc Med. 2017;3(1):e000222

57. Renstrom P, Ljungqvist A, Arendt E, et al.Non-contact ACL injuries in femaleathletes: an International OlympicCommittee current concepts statement.Br J Sports Med. 2008;42(6):394–412

58. Bedoya AA, Miltenberger MR, Lopez RM.Plyometric training effects on athleticperformance in youth soccer athletes:a systematic review. J Strength CondRes. 2015;29(8):2351–2360

59. Ramírez-Campillo R, Burgos CH,Henríquez-Olguín C, et al. Effect ofunilateral, bilateral, and combinedplyometric training on explosive andendurance performance of youngsoccer players. J Strength Cond Res.2015;29(5):1317–1328

60. Asadi A, Arazi H, Ramirez-Campillo R,Moran J, Izquierdo M. Influence of

PEDIATRICS Volume 145, number 6, June 2020 11 by guest on June 6, 2020www.aappublications.org/newsDownloaded from

maturation stage on agilityperformance gains after plyometrictraining: a systematic review and meta-analysis. J Strength Cond Res. 2017;31(9):2609–2617

61. Loudon JK, Santos MJ, Franks L, Liu W.The effectiveness of active exercise asan intervention for functional ankleinstability: a systematic review. SportsMed. 2008;38(7):553–563

62. Boström A, Thulin K, Fredriksson M,Reese D, Rockborn P, Hammar ML. Riskfactors for acute and overuse sportinjuries in Swedish children 11 to15 years old: what about resistancetraining with weights? Scand J Med SciSports. 2016;26(3):317–323

63. American Academy of FamilyPhysicians; American Academy ofOrthopaedic Surgeons; AmericanCollege of Sports Medicine; AmericanOrthopaedic Society for SportsMedicine; American OsteopathicAcademy of Sports Medicine; AmericanMedical Society for Sports Medicine.The team physician and strength andconditioning of athletes for sports:a consensus statement. Med Sci SportsExerc. 2015;47(2):440–445

64. Gabbett TJ, Whyte DG, Hartwig TB,Wescombe H, Naughton GA. Therelationship between workloads,physical performance, injury andillness in adolescent male footballplayers. Sports Med. 2014;44(7):989–1003

65. Brenner JS; American Academy ofPediatrics Council on Sports Medicineand Fitness. Overuse injuries,overtraining, and burnout in child andadolescent athletes. Pediatrics. 2007;119(6):1242–1245

66. Petrie HJ, Stover EA, Horswill CA.Nutritional concerns for the child andadolescent competitor. Nutrition. 2004;20(7–8):620–631

67. Cotunga N, Vickery CE, McBee S. Sportsnutrition for young athletes. J Sch Nurs.2005;21(6):323–328

68. Solomon ML, Weiss Kelly AK. Approachto the underperforming athlete. PediatrAnn. 2016;45(3):e91–e96

69. Solomon ML, Briskin SM, Sabatina N,Steinhoff JE. The pediatric enduranceathlete. Curr Sports Med Rep. 2017;16(6):428–434

70. Calderazzi F, Nosenzo A, Galavotti C,Menozzi M, Pogliacomi F, Ceccarelli F.Apophyseal avulsion fractures of thepelvis. A review. Acta Biomed. 2018;89(4):470–476

71. Browne TD, Yost RP, McCarron RF.Lumbar ring apophyseal fracture in anadolescent weight lifter. A case report.Am J Sports Med. 1990;18(5):533–535

72. US Consumer Product SafetyCommission. National Electronic InjurySurveillance System. Available at: www.cpsc.gov/library/neiss.html. AccessedOctober 9, 2019

73. Hamill B. Relative safety of weightliftingand weight training. J Strength CondRes. 1994;8(1):53–57

74. Byrd R, Pierce K, Rielly L, Brady J. Youngweightlifters’ performance across time.Sports Biomech. 2003;2(1):133–140

75. Harries SK, Lubans DR, Buxton A,MacDougall THJ, Callister R. Effects of12-week resistance training on sprintand jump performances in competitiveadolescent rugby union players.J Strength Cond Res. 2018;32(10):2762–2769

76. Kerr ZY, Collins CL, Comstock RD.Epidemiology of weight training-relatedinjuries presenting to United Statesemergency departments, 1990 to 2007.Am J Sports Med. 2010;38(4):765–771

77. Myer GD, Quatman CE, Khoury J, Wall EJ,Hewett TE. Youth versus adult“weightlifting” injuries presenting toUnited States emergency rooms:accidental versus nonaccidental injurymechanisms. J Strength Cond Res.2009;23(7):2054–2060

78. Mehrab M, de Vos RJ, Kraan GA,Mathijssen NMC. Injury incidence andpatterns among Dutch CrossFitathletes. Orthop J Sports Med. 2017;5(12):2325967117745263

79. Rice SG; American Academy ofPediatrics Council on Sports Medicineand Fitness. Medical conditionsaffecting sports participation.Pediatrics. 2008;121(4):841–848

80. Black HR, Sica D, Ferdinand K, White WB.Eligibility and disqualificationrecommendations for competitiveathletes with cardiovascularabnormalities: task force 6:hypertension: a scientific statementfrom the American Heart Association

and the American College of Cardiology.J Am Coll Cardiol. 2015;66(21):2393–2397

81. International League Against Epilepsy.ILAE Commission report. Restrictionsfor children with epilepsy. Commissionof Pediatrics of the ILAE. Epilepsia. 1997;38(9):1054–1056

82. Knowles BD, Pleacher MD. Athletes withseizure disorders. Curr Sports MedRep. 2012;11(1):16–20

83. Maron BJ, Chaitman BR, Ackerman MJ,et al; Working Groups of the AmericanHeart Association Committee onExercise, Cardiac Rehabilitation, andPrevention; Councils on ClinicalCardiology and Cardiovascular Diseasein the Young. Recommendations forphysical activity and recreationalsports participation for young patientswith genetic cardiovascular diseases.Circulation. 2004;109(22):2807–2816

84. Fiuza-Luces C, Padilla JR, Soares-Miranda L, et al. Exercise intervention inpediatric patients with solid tumors:the physical activity in pediatric cancertrial. Med Sci Sports Exerc. 2017;49(2):223–230

85. Steinherz LJ, Steinherz PG, Tan CT,Heller G, Murphy ML. Cardiac toxicity 4to 20 years after completinganthracycline therapy. JAMA. 1991;266(12):1672–1677

86. Gomez J; American Academy ofPediatrics Committee on SportsMedicine and Fitness. Use ofperformance-enhancing substances.Pediatrics. 2005;115(4):1103–1106

87. Myer GD, Faigenbaum AD, Ford KR, BestTM, Bergeron MF, Hewett TE. When toinitiate integrative neuromusculartraining to reduce sports-relatedinjuries and enhance health in youth?Curr Sports Med Rep. 2011;10(3):155–166

88. Faigenbaum A, Bruno L. A fundamentalapproach for treating pediatricdynapenia in kids. ACSM’s Health Fit J.2017;21:18–24

89. Kakebeeke TH, Locatelli I, Rousson V,Caflisch J, Jenni OG. Improvement ingross motor performance between 3and 5 years of age. Percept Mot Skills.2012;114(3):795–806

90. Smith JJ, DeMarco M, Kennedy SG, et al.Prevalence and correlates of resistance

12 FROM THE AMERICAN ACADEMY OF PEDIATRICS by guest on June 6, 2020www.aappublications.org/newsDownloaded from

training skill competence inadolescents. J Sports Sci. 2018;36(11):1241–1249

91. Hackett D, Davies T, Soomro N, Halaki M.Olympic weightlifting training improvesvertical jump height in sportspeople:a systematic review with meta-analysis.Br J Sports Med. 2016;50(14):865–872

92. Logan K, Cuff S; Council on SportsMedicine and Fitness. Clinical report:organized sports for children,preadolescents, and adolescents.Pediatrics. 2019;143(6):e20190997

93. Gabbett TJ, Nassis GP, Oetter E, et al. Theathlete monitoring cycle: a practicalguide to interpreting and applying

training monitoring data. Br J SportsMed. 2017;51(20):1451–1452

94. Coutts AJ, Murphy AJ, Dascombe BJ.Effect of direct supervision ofa strength coach on measures ofmuscular strength and power in youngrugby league players. J Strength CondRes. 2004;18(2):316–323

PEDIATRICS Volume 145, number 6, June 2020 13 by guest on June 6, 2020www.aappublications.org/newsDownloaded from

originally published online May 26, 2020; Pediatrics SPORTS MEDICINE AND FITNESS

Paul R. Stricker, Avery D. Faigenbaum, Teri M. McCambridge and COUNCIL ONResistance Training for Children and Adolescents

ServicesUpdated Information &

020-1011http://pediatrics.aappublications.org/content/early/2020/05/22/peds.2including high resolution figures, can be found at:

References

020-1011#BIBLhttp://pediatrics.aappublications.org/content/early/2020/05/22/peds.2This article cites 93 articles, 20 of which you can access for free at:

Subspecialty Collections

cal_fitness_subhttp://www.aappublications.org/cgi/collection/sports_medicine:physiSports Medicine/Physical Fitnessfollowing collection(s): This article, along with others on similar topics, appears in the

Permissions & Licensing

http://www.aappublications.org/site/misc/Permissions.xhtmlin its entirety can be found online at: Information about reproducing this article in parts (figures, tables) or

Reprintshttp://www.aappublications.org/site/misc/reprints.xhtmlInformation about ordering reprints can be found online:

by guest on June 6, 2020www.aappublications.org/newsDownloaded from

originally published online May 26, 2020; Pediatrics SPORTS MEDICINE AND FITNESS

Paul R. Stricker, Avery D. Faigenbaum, Teri M. McCambridge and COUNCIL ONResistance Training for Children and Adolescents

http://pediatrics.aappublications.org/content/early/2020/05/22/peds.2020-1011located on the World Wide Web at:

The online version of this article, along with updated information and services, is

ISSN: 1073-0397. 60007. Copyright © 2020 by the American Academy of Pediatrics. All rights reserved. Print the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois,has been published continuously since 1948. Pediatrics is owned, published, and trademarked by Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it

by guest on June 6, 2020www.aappublications.org/newsDownloaded from