Advertising Disclaimer »

PEDIATRICS COVID-19 COLLECTION
We are fast-tracking and publishing the latest research and articles related to COVID-19 for free. View the collection.

This policy is a revision of the policy in

From the American Academy of PediatricsClinical Report

Use of Performance-Enhancing Substances

Michele LaBotz, Bernard A. Griesemer and COUNCIL ON SPORTS MEDICINE AND FITNESS
Pediatrics July 2016, 138 (1) e20161300; DOI: https://doi.org/10.1542/peds.2016-1300
Download PDF

Abstract

Performance-enhancing substances (PESs) are used commonly by children and adolescents in attempts to improve athletic performance. More recent data reveal that these same substances often are used for appearance-related reasons as well. PESs include both legal over-the-counter dietary supplements and illicit pharmacologic agents. This report reviews the current epidemiology of PES use in the pediatric population, as well as information on those PESs in most common use. Concerns regarding use of legal PESs include high rates of product contamination, correlation with future use of anabolic androgenic steroids, and adverse effects on the focus and experience of youth sports participation. The physical maturation and endogenous hormone production that occur in adolescence are associated with large improvements in strength and athletic performance. For most young athletes, PES use does not produce significant gains over those seen with the onset of puberty and adherence to an appropriate nutrition and training program.

  • Abbreviations:
    AAP —
    American Academy of Pediatrics
    AAS —
    anabolic-androgenic steroid
    FDA —
    US Food and Drug Administration
    hGH —
    human growth hormone
    MTF —
    Monitoring the Future
    NCAA —
    National Collegiate Athletic Administration
    PATS —
    Partnership Attitude Tracking Study
    PES —
    performance-enhancing substance
    USADA —
    US Anti-Doping Agency
    YRBSS —
    Youth Risk Behavior Surveillance System

    • Introduction

    The American Academy of Pediatrics (AAP) has published position papers, a subject review, guidelines, and textbook chapters regarding the use of performance-enhancing substances (PESs) by children and adolescents.1–3 This clinical report updates and consolidates information on this topic. For the purposes of this report, the term “performance-enhancing substances” will be used to describe the spectrum of dietary supplements, as well as legal and illegal drugs that often are used by athletes for the purpose of improving athletic performance.

    Over the last 2 decades, the availability of PESs has increased with access to Internet suppliers, proliferation, and marketing of stimulant-containing beverages, and increasing use of topically applied anabolic androgenic steroids. Although the overall use of many PESs may have declined over the past 15 years, reviews of multiple studies have prompted concern that the onset of use may be occurring increasingly in the pediatric population.4

    Epidemiology of PES Use in the Pediatric Population

    Several national studies have been tracking adolescent use of PESs. Monitoring the Future (MTF) is an annual survey of 50 000 students in eighth, 10th, and 12th grade.5 Figs 1, 2, 3, and 4 outline results and trends of PES use as noted in MTF. The Youth Risk Behavior Surveillance System (YRBSS) is a biennial survey that includes a representative cross-section of high school students in the United States. The 2013 YRBSS included surveys from more than 13 500 students and revealed prevalence rates for nonprescribed steroid use that were a bit higher than those in MTF, with 3.2% reporting lifetime use of anabolic androgenic steroids.6 The reported number was higher in boys (4.0%) than in girls (2.2%) and indicated a significant decrease over the previous 12 years, from a high of 5.0% overall use in 2001.

    FIGURE 1
    FIGURE 1

    Percentage of eighth, 10th, and 12th graders reporting any lifetime use of anabolic androgenic steroids by year and sex (data from MTF, 2014).5

    FIGURE 2
    FIGURE 2

    Percentage of eighth, 10th, and 12th graders reporting any lifetime use of creatine by year and sex (data from MTF, 2014).5

    FIGURE 3
    FIGURE 3

    Percentage of eighth, 10th, and 12th graders reporting any lifetime use of androstenedione by year and sex (data from MTF, 2014).5

    FIGURE 4
    FIGURE 4

    Percentage of eighth, 10th, and 12th graders reporting any lifetime use of nonprescription diet pills by sex (data from MTF, 2014).5

    The Partnership Attitude Tracking Study (PATS) is an annual survey of parents and high school students regarding behaviors and attitudes about drugs and substance abuse.7 The 2013 PATS survey included responses from more than 3700 students. Steroid use increased slightly from 5% to 7% as compared with 2012. However, use of synthetic human growth hormone (hGH) almost doubled, from 5% to 11%, after being fairly stable from 2009–2012. The report stated that most of this increase included teenagers who reported a single episode of hGH use and that the number of teenagers who report having used hGH more often has remained consistent.

    Several studies have demonstrated polypharmacy among users of PESs, with elevated rates of use of both recreational drugs and multiple PESs.5,8,9 MTF has demonstrated a strong association between use of androstenedione, creatine, and anabolic androgenic steroids. Approximately 80% of androstenedione users and more than one-third of steroid users also use creatine. Between 2010 and 2012, approximately half of androstenedione users also were using anabolic androgenic steroids; however, this decreased to 15% in 2013. Younger creatine users are much more likely to be using multiple PESs than their older counterparts (Table 1).

    View this table:
    TABLE 1

    Polypharmacy in PES Use5

    For many adolescents, use of PESs is an attempt to enhance appearance rather than performance, and many users are not actively involved in organized athletic activity. Terms such as “performance- and image-enhancing substances” and “appearance- and performance-enhancing drugs” emphasize their broader appeal.10–13 A Minnesota study evaluating various muscle-enhancing behaviors revealed that in an urban high school population, 38.8% of boys and 18.2% of girls reported a history of protein supplement use.11 The same study revealed rates of use in middle school for boys and girls as 29.7% and 24.7%, respectively. Although students participating in team sports were more likely to use protein supplements (24.2%), it is worth noting that use of protein supplements still was fairly high in students who were not involved in sports (18.2%).11

    Corroborating this higher use of PESs in an athletic population, a 2012 meta-analysis revealed higher rates of steroid use in athletes than in nonathletes (odds ratio, 1.5).14 In addition to sports participation, other correlates of PES use include body dissatisfaction,12 higher BMI,11 training in a commercial gym,15 and exposure to appearance-focused media.13 The latter was particularly true for the genre of “fitness” media, which tends to have a large focus on muscle development, as opposed to the genre of more traditional sports-reporting media. Multiple studies have revealed correlations between PES use and alcohol and drug use, as well as other risk-taking behaviors.15–17

    Different patterns of use have been identified between boy and girl PES users. Girls report much lower rates of using substances that are generally associated with gains in strength and muscle mass, such as creatine, androstenedione, and anabolic androgenic steroids, and these differences grow larger with age.5 Conversely, girls report much higher rates of using nonprescription diet pills. Although this is consistent with traditional perceptions of male pursuit of muscularity and female pursuit of thinness, it is important to note that in 2013, 4% of boys reported use of diet pills in 2013, and 1% to 2% of 12th-grade girls reported use of creatine and anabolic androgenic steroids.5,6

    It is unclear how race and ethnicity may correlate with PES use. YRBSS data revealed higher rates of steroid use in 2013 among Hispanic students (4.2%) as compared with students who identified themselves as white (2.8%) or African American (2.3%).6 These differences were not noted for 12th graders in the 2013 MTF data, in which steroid use rates within these groups were all just under 2.0%.5 One study revealed increased rates of steroid use among Asian students (primarily Hmong) as compared with white students, with odds ratios of 3.51 and 3.37 for boys and girls, respectively.11 The PATS revealed that hGH use was significantly higher in African American and Hispanic teenagers as compared with white teenagers, with use rates of 15%, 13%, and 9% respectively.7

    Regulation of PESs

    The most commonly used PESs in the adolescent population generally are sold over the counter as dietary supplements. The Dietary Supplement Health and Education Act of 1994 (Pub L No. 103-417) created supplements as a category not subject to US Food and Drug Administration (FDA) approval for safety or efficacy before coming to market. Supplements often are intermingled with foods, beverages, and over-the-counter medications on retail shelves, and it is difficult for the consumer to differentiate products with ingredients subject to strong FDA oversight from products that are subject to the looser controls, as allowed by the Dietary Supplement Health and Education Act.

    Given the lack of manufacturing oversight, consumers of these goods risk using products that are contaminated or missing ingredients. Several studies that tested protein supplements revealed that 8% to 20% of these products were contaminated with significant amounts of heavy metals.18 An analysis of supplements obtained from US retailers in 2007 revealed that 25% of these were contaminated with anabolic androgenic steroids, and 11% were contaminated with stimulants.18 In 2015, the New York attorney general sent cease-and-desist letters to 4 national retailers after an investigation revealed that only 5 of 20 herbal supplement products tested consistently contained active ingredients as listed.19

    Caffeine is unique in that it is ingested as a dietary supplement but also is contained in many foods that are common in the American diet. Although the FDA does regulate the amount of caffeine in foods (eg, soft drinks are allowed a maximum of 71 mg of caffeine/12 oz), the amount of caffeine in energy drinks and other dietary supplements is not regulated. Additional information on caffeine can be found in Fig 3, as well as the AAP clinical report “Sports Drinks and Energy Drinks for Children and Adolescents: Are They Appropriate?” which specifically states that energy drinks containing stimulants should never be consumed by children and adolescents.20

    The Anabolic Steroid Control Acts of 1990 (Pub L No. 101-647) and 2004 (Pub L No. 108-358) classified anabolic androgenic steroids, as well as certain precursors that were previously marketed as supplements (such as androstenedione), as Schedule III drugs. The Designer Anabolic Steroid Control Act of 2014 (Pub L No. 113-260) further expanded the definition of “anabolic steroid” in part to address the expansion of synthetic prohormones that were developed after passage of the 2004 act. These prohormones are all now classified as Schedule III anabolic steroid drugs, and possession or use of any of these substances without a physician’s prescription is prohibited by state and federal laws.

    Summary of PES Mechanisms and Effects

    A vast number of substances are purported to have ergogenic (ie, performance-enhancing) effects. Claims of performance enhancement with different drugs and supplements are constantly evolving. Initial claims of significant performance enhancement are often made on the Internet as well as in body-building and fitness magazines. These claims most often are unsubstantiated or based on findings from single or poorly designed studies. As these substances undergo further scrutiny, it is common for these initial claims to be debunked, and the evidence often does not support earlier assertions of performance benefit. Although it is not possible to provide a fully comprehensive list of PESs, Table 2 provides an overview of substances that are most widely known and studied in the pediatric population.

    View this table:
    TABLE 2

    Summary Table of PES Prevalence, Effects, and Safety Concerns in Children and Adolescents

    Any potential ergogenic effects of PESs can be contrasted to the great improvements in strength and athletic performance often observed in child and adolescent athletes attributable to the combined effects of training and development. Typical strength gains of approximately 30% are reported in youth resistance training programs of 8 to 20 weeks’ duration.43 Supplements or nutritional interventions that are currently available and legal cannot rival this rate of gain. The best advice for performance-related concerns in young athletes is to focus on the basics of appropriate training and nutritional practices as outlined in Table 3. PESs are not “shortcuts” to higher levels of athletic performance, and they cannot compensate for athletes who do not adhere to the basic principles of good training and nutrition.

    View this table:
    TABLE 3

    Training Principles to Enhance Athletic Performance

    Concerns Regarding PES Use

    The goals of the antidoping movement in sports are to protect the health of athletes and to prevent unfair competition, and use of PESs is identified in a survey of adults as the most serious issue facing sports today.46 Potential health risks are outlined for individual substances in Table 2. In addition, the “gateway hypothesis” of adolescent substance abuse may apply with PES use. Although causation is difficult to prove, initial use of legal ergogenic supplements appears to reduce barriers to future nontherapeutic use of anabolic androgenic steroids by increasing social contacts with other users of PESs, as well as changing perceived social norms and attitudes regarding the safety and efficacy of illicit PES use.10,47,48

    The moral implications of PES use contribute to concerns about cheating and unfair competition and may have adverse effects on the youth sports experience.46 The top 5 issues of importance reported by children and adolescents regarding participation in sports are, in order: having fun, doing one’s best, being with friends, improving skills, and being healthy. PES use shifts the focus of athletes from the pleasure and camaraderie of sports participation to that of gaining competitive advantage.

    Drug Testing and Screening

    Home

    Home drug tests are aggressively marketed on the Internet to parents with concerns about drug use. In a 2014 clinical report, the AAP stated it does not endorse home drug testing because of concerns about lack of efficacy, potential misinterpretation of test results, and the potential negative effect on the parent–child relationship.49 The AAP recommends that parents’ concerns about drug testing be addressed in cooperation with health care providers.

    Office Based

    Use of PESs often is clinically occult in the pediatric population, without reliable changes that can be detected on physical examination. Bright Futures contains information regarding office assessment, as well as patient and parent education and guidance when substance abuse is a concern.50 Suggestions include screening for substance use as part of an age-appropriate comprehensive history and asking open-ended questions about substance use at home, at school, and by peers before progressing to questions about personal use.

    The Preparticipation Physical Evaluation form developed by the AAP (https://www.aap.org/en-us/professional-resources/practice-support/Documents/Preparticipation-Physical-Exam-Form.pdf) contains several questions regarding use of PESs. Although sensitivity of these questions has not been studied, the questions provide an opportunity for further discussion and guidance and are as follows:

    • Do you drink alcohol or use other drugs?

    • Have you ever taken anabolic androgenic steroids or used any other performance supplement?

    • Have you ever taken any supplements to help you gain or lose weight or improve your performance?

    The AAP does not endorse general drug use screening by pediatric health care providers but has published guidelines for drug testing in the pediatric office when there is clinical suspicion of use.49

    High Schools

    Testing in schools often is proposed not only to provide a mechanism for detecting drug use but also to serve as a deterrent. In 1995, the US Supreme Court ruled that random drug testing of student athletes does not violate the Fourth Amendment, and in 2002, the Court rendered a parallel opinion regarding students participating in other extracurricular activities.51 Since then, schools in a number of states have initiated mandatory-random student drug testing; however, the efficacy of these programs in detecting and preventing drug use is unclear. The University Interscholastic League in Texas runs 1 of the largest high school drug testing programs in the United States. In 2013–2014, the University Interscholastic League conducted 2633 tests for anabolic androgenic steroids with 2 positive results, 7 protocol violations (ie, student did not show up for the test), and 10 inconclusive results.52 Given the prevalence of information available on how to avoid positive anabolic-androgenic steroid (AAS) test results, it is impossible to know whether this low rate of positive results was a true reflection of reduced AAS use in this population or the result of successful efforts at evading detection.

    Given the association of AAS use with other risk-taking behaviors, information concerning the effects of these programs on overall rates of drug use may be pertinent. The limited number of studies evaluating school-based drug testing reveal mixed results regarding deterrent effect on use of AAS and other illicit drugs, with 1 study documenting increased rates of risk factors for future drug use.53,54 Because of concerns regarding poor sensitivity, use of limited school resources, and potential adverse effects on student attitudes and behaviors, the AAP does not endorse widespread implementation of school-based testing.53

    College/Elite

    Athletes who are participating at collegiate, elite, or national levels are subject to specific restrictions and possible testing for a variety of ergogenic aids. Therapeutic use of certain medications by the athlete (eg, many attention-deficit/hyperactivity disorder medications, β2-agonists, diuretics) may require physician certification. Additional information for athletes and their health care providers is available as follows:

    • US Anti-Doping Agency (USADA) runs the antidoping program for the Olympic/Paralympic/Pan American movements. The Web site (http://www.usada.org) includes general educational information, as well as a link to the World Anti-Doping Agency prohibited drug list.

    • National Collegiate Athletic Administration (NCAA) maintains Web pages providing information on its banned drug list, testing, and medical exception procedures (http://www.ncaa.org/themes/topics/drug-testing).

    • National Center for Drug Free Sport administers drug-testing programs for the NCAA, as well as many professional leagues and state high school associations. The Web site (http://www.drugfreesport.com) includes additional testing information, as well as a subscription-based information center.

    Education and Prevention

    General

    Opinions of and information received from family members, school professionals, teammates, coaches, and health care providers all contribute to decision-making about PES use in the pediatric population. When adolescents are considering using PESs, the potential for benefit with PES use appears to outweigh dissuasive factors significantly.55 Therefore, prevention efforts that are directed solely at avoidance of adverse consequences of PES use (ie, getting caught, cost) are likely to be less effective than efforts that focus on the lack of realized benefit for users of PES.

    Educating athletes and families on basic training principles for pursuit of peak athletic performance may be helpful and should be emphasized as an alternative to PES use (Table 3). USADA provides a comprehensive handbook on this topic for parents, which can be accessed at http://www.truesport.org/library/documents/resources/nutrition_guide/NutritionGuide.pdf.

    School/Sports Team

    Information contained in the AAP clinical report “The Role of Schools in Combating Illicit Substance Abuse” also is pertinent regarding PES use; however, it does not explicitly address the issue of substances that are used in pursuit of ergogenic benefit.56 The National Institute for Drug Abuse provides teaching materials that cover use of anabolic androgenic steroids and stimulants on its Web site (http://teens.drugabuse.gov/educators/nida-teaching-guides/mind-over-matter/teachers-guide).

    Adolescents Training and Learning to Avoid Steroids and Athletes Targeting Healthy Exercise and Nutrition Alternatives are programs designed to address PES use in adolescent boys and girls, respectively.57 These structured, sport-centered programs are led by peers with coach facilitation and are considered by the World Anti-Doping Agency as the most rigorously studied and effective way to educate adolescents about doping.58 Both of these programs were developed at Oregon Health and Science University, and additional information can be found at http://www.ohsu.edu/xd/education/schools/school-of-medicine/departments/clinical-departments/medicine/divisions/hpsm/research/index.cfm.

    The Taylor Hooton Foundation provides educational resources for schools and other groups. This includes school-based presentations, as well as educational infographics and posters that can be downloaded at no cost (www.http://taylorhooton.org/education-resources/downloads/).

    Home

    Many resources for parents of athletes include information on how to educate and prevent their athletes from using PESs. Publications from USADA cover a variety of issues pertinent to parents of athletes (http://www.truesport.org/library/documents/resources/parent/parent_handbook.pdf). Table 4 summarizes guidance for parents provided by the Partnership for Drug-Free Kids.

    View this table:
    TABLE 4

    Guidance for Parents With Concerns About PES Use59

    Additional Resources

    For Health Care Professionals

    Trends in PES use are subject to rapid change, with many substances having short-lived reputations as ergogenic aids. A combination of aggressive Internet marketing efforts and the lack of regulatory oversight can make it difficult to assess reliability of information sources on this topic. General information on a broad variety of specific substances is available in the British Journal of Sports Medicine series “A-Z of Nutritional Supplements: Dietary Supplements, Sports Nutrition Foods and Ergogenic Aids for Health and Performance (www.bjsm.bmj.com).”

    For Parents and Athletes

    The USADA Web site (http://www.usada.org/substances/) contains information on specific supplements and performance-enhancing drugs and information on how to assess ergogenic claims and make informed decisions regarding dietary supplement use.

    Summary

    1. PES use is common in adolescence, and these substances are used in attempts to enhance both physical performance and appearance.

    2. Throughout adolescence, use of all PESs tends to increase with age and is higher in athletes than in nonathletes.

    3. Boys are at higher risk than girls for most PES use. Other risk factors for PES use include body dissatisfaction, higher BMI, training in a commercial gym, exposure to appearance-oriented fitness media, use of alcohol or drugs, and other risk-taking behaviors.

    4. PESs most commonly used by adolescents are protein supplements, creatine, and caffeine.

    5. Many PESs are sold over the counter as dietary supplements. Athletes and parents often are unaware of the lack of FDA oversight of supplements and the risk of contamination with prohibited substances or absent active ingredients in these products.

    6. Onset of endogenous hormone secretion during puberty, in combination with appropriate training techniques, is associated with large gains in strength and overall athletic performance. This is particularly true after the onset of peak height velocity. For most adolescent athletes, PES use will not produce significant improvements above those attained with adherence to appropriate nutrition and training fundamentals during this time.

    7. It can be difficult to keep pace with the frequent reports of newly recognized PESs. Although the majority of initial reports of PES benefit are subsequently discredited after further study, it can be helpful for pediatric health care providers to steer patients and families to reputable Web-based resources for further evaluation of PES claims.

    8. There is concern that initial use of over-the-counter PESs may be associated with increased risk of future anabolic steroid use and other risk-taking behaviors. Younger PES users appear to be at greater risk of polypharmacy.

    Lead Authors

    Michele LaBotz, MD, FAAP

    Bernard A. Griesemer, MD, FAAP

    Council on Sports Medicine and Fitness Executive Committee, 2014–2015

    Joel S. Brenner, MD, MPH, FAAP, Chairperson

    Cynthia R. LaBella, MD, FAAP, Chairperson-Elect

    Margaret A. Brooks, MD, FAAP

    Alex Diamond, DO, MPH, FAAP

    Amanda K. Weiss Kelly, MD, FAAP

    Michele LaBotz, MD, FAAP

    Kelsey Logan, MD, MPH, FAAP

    Keith J. Loud, MDCM, MSc, FAAP

    Kody A. Moffatt, MD, FAAP

    Blaise Nemeth, MD, MS, FAAP

    Brooke Pengel, MD, FAAP

    William Hennrikus, MD, FAAP

    Liaisons

    Andrew J. M. Gregory, MD, FAAP – American College of Sports Medicine

    Mark E. Halstead, MD, FAAP – American Medical Society for Sports Medicine

    Lisa K. Kluchurosky, MEd, ATC – National Athletic Trainers Association

    Consultants

    Rebecca Demorest, MD, FAAP

    Neeru A. Jayanthi, MD

    Steven Cuff, MD, FAAP

    David Smith, MD, FAAP

    Staff

    Anjie Emanuel, MPH

    Footnotes

    • Clinical reports from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. However, clinical reports from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent.

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

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

    References

    1. ↵
      1. Gomez J; American Academy of Pediatrics Committee on Sports Medicine and Fitness
      . Use of performance-enhancing substances. Pediatrics. 2005;115(4):1103–1106pmid:15805399
      OpenUrlAbstract/FREE Full Text
      1. American Academy of Pediatrics. Committee on Sports Medicine and Fitness
      . Adolescents and anabolic steroids: a subject review. Pediatrics. 1997;99(6):904–908pmid:9190555
      OpenUrlAbstract/FREE Full Text
    3. ↵
      1. American Academy of Pediatrics, American Academy of Orthopaedic Surgeons
      . Performance enhancing substances. In: American Academy of Pediatrics, American Academy of Orthopaedic Surgeons, eds. Care of the Young Athlete. Elk Grove Village, IL: American Academy of Pediatrics; 2000:95–104
    4. ↵
      1. Hoffman JR,
      2. Faigenbaum AD,
      3. Ratamess NA,
      4. Ross R,
      5. Kang J,
      6. Tenenbaum G
      . Nutritional supplementation and anabolic steroid use in adolescents. Med Sci Sports Exerc. 2008;40(1):15–24pmid:18091024
      OpenUrlCrossRefPubMed
    5. ↵
      1. Johnston LD,
      2. O’Malley PM,
      3. Bachman JG,
      4. Schulenberg JE,
      5. Miech RA
      . Monitoring the Future: National Survey Results on Drug Use, 1975–2013, Vol. I: Secondary School Students. Ann Arbor, MI: Institute for Social Research, The University of Michigan; 2014
    6. ↵
      1. Kann L,
      2. Kinchen S,
      3. Shanklin SL, et al; Centers for Disease Control and Prevention (CDC)
      . Youth risk behavior surveillance--United States, 2013. MMWR Suppl. 2014;63(4 SS-4):1–168pmid:24918634
      OpenUrlPubMed
    7. ↵
      1. Partnership for Drug-Free Kids
      . The 2013 Partnership Attitude Tracking Study. Available at: www.drugfree.org/newsroom/pats-2013-teens-report-higher-use-of-performance-enhancing-substances. Accessed September 22, 2015
    8. ↵
      1. Hatton CK,
      2. Green GA,
      3. Ambrose PJ
      . Performance-enhancing drugs: understanding the risks. Phys Med Rehabil Clin N Am. 2014;25(4):897–913pmid:25442165
      OpenUrlCrossRefPubMed
    9. ↵
      1. Hoffman JR,
      2. Kraemer WJ,
      3. Bhasin S, et al
      . Position stand on androgen and human growth hormone use. J Strength Cond Res. 2009;23(suppl 5):S1–S59pmid:19620932
      OpenUrlCrossRefPubMed
    10. ↵
      1. Hildebrandt T,
      2. Harty S,
      3. Langenbucher JW
      . Fitness supplements as a gateway substance for anabolic-androgenic steroid use. Psychol Addict Behav. 2012;26(4):955–962pmid:22486333
      OpenUrlCrossRefPubMed
    11. ↵
      1. Eisenberg ME,
      2. Wall M,
      3. Neumark-Sztainer D
      . Muscle-enhancing behaviors among adolescent girls and boys. Pediatrics. 2012;130(6):1019–1026pmid:23166333
      OpenUrlAbstract/FREE Full Text
    12. ↵
      1. Yager Z,
      2. O’Dea JA
      . Relationships between body image, nutritional supplement use, and attitudes towards doping in sport among adolescent boys: implications for prevention programs. J Int Soc Sports Nutr. 2014;11(1):13pmid:24670105
      OpenUrlCrossRefPubMed
    13. ↵
      1. Frison E,
      2. Vandenbosch L,
      3. Eggermont S
      . Exposure to media predicts use of dietary supplements and anabolic-androgenic steroids among Flemish adolescent boys. Eur J Pediatr. 2013;172(10):1387–1392pmid:23748985
      OpenUrlCrossRefPubMed
    14. ↵
      1. Diehl K,
      2. Thiel A,
      3. Zipfel S,
      4. Mayer J,
      5. Litaker DG,
      6. Schneider S
      . How healthy is the behavior of young athletes? A systematic literature review and meta-analyses. J Sports Sci Med. 2012;11(2):201–220pmid:24149192
      OpenUrlPubMed
    15. ↵
      1. Dodge T,
      2. Hoagland MF
      . The use of anabolic androgenic steroids and polypharmacy: a review of the literature. Drug Alcohol Depend. 2011;114(2-3):100–109pmid:21232881
      OpenUrlPubMed
      1. Buckman JF,
      2. Farris SG,
      3. Yusko DA
      . A national study of substance use behaviors among NCAA male athletes who use banned performance enhancing substances. Drug Alcohol Depend. 2013;131(1-2):50–55pmid:23688842
      OpenUrlCrossRefPubMed
    17. ↵
      1. Buckman JF,
      2. Yusko DA,
      3. White HR,
      4. Pandina RJ
      . Risk profile of male college athletes who use performance-enhancing substances. J Stud Alcohol Drugs. 2009;70(6):919–923pmid:19895768
      OpenUrlCrossRefPubMed
    18. ↵
      1. Maughan RJ
      . Quality assurance issues in the use of dietary supplements, with special reference to protein supplements. J Nutr. 2013;143(11):1843S–1847Spmid:24027186
      OpenUrlAbstract/FREE Full Text
    19. ↵
      1. O’Connor A
      . New York Attorney General targets supplements at major retailers. New York Times. February 3, 2015. Available at: http://well.blogs.nytimes.com/2015/02/03/new-york-attorney-general-targets-supplements-at-major-retailers/. Accessed September 23, 2015
    20. ↵
      1. Committee on Nutrition and the Council on Sports Medicine and Fitness
      . Sports drinks and energy drinks for children and adolescents: are they appropriate? Pediatrics. 2011;127(6):1182–1189pmid:21624882
      OpenUrlAbstract/FREE Full Text
      1. Hall M,
      2. Trojian TH
      . Creatine supplementation. Curr Sports Med Rep. 2013;12(4):240–244pmid:23851411
      OpenUrlCrossRefPubMed
      1. Kim HJ,
      2. Kim CK,
      3. Carpentier A,
      4. Poortmans JR
      . Studies on the safety of creatine supplementation. Amino Acids. 2011;40(5):1409–1418pmid:21399917
      OpenUrlCrossRefPubMed
      1. King DS,
      2. Baskerville R,
      3. Hellsten Y, et al
      . A-Z of nutritional supplements: dietary supplements, sports nutrition foods and ergogenic aids for health and performance: Part 34. Br J Sports Med. 2012;46(9):689–690pmid:22711798
      OpenUrlFREE Full Text
      1. Castell LM,
      2. Burke LM,
      3. Stear SJ
      . BJSM reviews: A-Z of supplements: dietary supplements, sports nutrition foods and ergogenic aids for health and performance Part 2. Br J Sports Med. 2009;43(11):807–810pmid:19864589
      OpenUrlFREE Full Text
      1. Branum AM,
      2. Rossen LM,
      3. Schoendorf KC
      . Trends in caffeine intake among U.S. children and adolescents. Pediatrics. 2014;133(3):386–393pmid:24515508
      OpenUrlAbstract/FREE Full Text
      1. Warren GL,
      2. Park ND,
      3. Maresca RD,
      4. McKibans KI,
      5. Millard-Stafford ML
      . Effect of caffeine ingestion on muscular strength and endurance: a meta-analysis. Med Sci Sports Exerc. 2010;42(7):1375–1387pmid:20019636
      OpenUrlCrossRefPubMed
      1. Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality
      . The DAWN Report: Update on Emergency Department Visits Involving Energy Drinks: A Continuing Public Health Concern. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2013
      1. Ahluwalia N,
      2. Herrick K,
      3. Moshfegh A,
      4. Rybak M
      . Caffeine intake in children in the United States and 10-y trends: 2001-2010. Am J Clin Nutr. 2014;100(4):1124–1132pmid:25240076
      OpenUrlAbstract/FREE Full Text
      1. Veliz P,
      2. Boyd C,
      3. McCabe SE
      . Adolescent athletic participation and nonmedical Adderall use: an exploratory analysis of a performance-enhancing drug. J Stud Alcohol Drugs. 2013;74(5):714–719pmid:23948530
      OpenUrlCrossRefPubMed
      1. Rowlands DS,
      2. Thomson JS
      . Effects of beta-hydroxy-beta-methylbutyrate supplementation during resistance training on strength, body composition, and muscle damage in trained and untrained young men: a meta-analysis. J Strength Cond Res. 2009;23(3):836–846pmid:19387395
      OpenUrlCrossRefPubMed
      1. Currell K,
      2. Derave W,
      3. Everaert I, et al
      . A-Z of nutritional supplements: dietary supplements, sports nutrition foods and ergogenic aids for health and performance: Part 20. Br J Sports Med. 2011;45(6):530–532pmid:21478504
      OpenUrlFREE Full Text
      1. Portal S,
      2. Zadik Z,
      3. Rabinowitz J, et al
      . The effect of HMB supplementation on body composition, fitness, hormonal and inflammatory mediators in elite adolescent volleyball players: a prospective randomized, double-blind, placebo-controlled study. Eur J Appl Physiol. 2011;111(9):2261–2269pmid:21327797
      OpenUrlCrossRefPubMed
      1. Liu H,
      2. Bravata DM,
      3. Olkin I, et al
      . Systematic review: the effects of growth hormone on athletic performance. Ann Intern Med. 2008;148(10):747–758pmid:18347346
      OpenUrlCrossRefPubMed
      1. Baumann GP
      . Growth hormone doping in sports: a critical review of use and detection strategies. Endocr Rev. 2012;33(2):155–186pmid:22368183
      OpenUrlCrossRefPubMed
      1. Sandbakk SB,
      2. Sandbakk O,
      3. Peacock O, et al.
      Effects of acute supplementation of L-arginine and nitrate on endurance and sprint performance in elite athletes. Nitric Oxide. 2015;48:10–15
      OpenUrlCrossRefPubMed
      1. Clements WT,
      2. Lee S-R,
      3. Bloomer RJ
      . Nitrate ingestion: a review of the health and physical performance effects. Nutrients. 2014;6(11):5224–5264pmid:25412154
      OpenUrlCrossRefPubMed
      1. Bond H,
      2. Morton L,
      3. Braakhuis AJ
      . Dietary nitrate supplementation improves rowing performance in well-trained rowers. Int J Sport Nutr Exerc Metab. 2012;22(4):251–256pmid:22710356
      OpenUrlPubMed
      1. Castell LM,
      2. Burke LM,
      3. Stear SJ,
      4. McNaughton LR,
      5. Harris RC
      . BJSM reviews: A-Z of nutritional supplements: dietary supplements, sports nutrition foods and ergogenic aids for health and performance Part 5. Br J Sports Med. 2010;44(1):77–78pmid:20026699
      OpenUrlFREE Full Text
      1. Zajac A,
      2. Cholewa J,
      3. Poprzecki S,
      4. Waskiewicz Z,
      5. Langfort J
      . Effects of sodium bicarbonate ingestion on swim performance in youth athletes. J Sports Sci Med. 2009;8(1):45–50pmid:24150555
      OpenUrlPubMed
      1. Hobson RM,
      2. Saunders B,
      3. Ball G,
      4. Harris RC,
      5. Sale C
      . Effects of β-alanine supplementation on exercise performance: a meta-analysis. Amino Acids. 2012;43(1):25–37pmid:22270875
      OpenUrlCrossRefPubMed
      1. Thomsen JJ,
      2. Rentsch RL,
      3. Robach P, et al
      . Prolonged administration of recombinant human erythropoietin increases submaximal performance more than maximal aerobic capacity. Eur J Appl Physiol. 2007;101(4):481–486pmid:17668232
      OpenUrlCrossRefPubMed
      1. Deligiannis AP,
      2. Kouidi EI
      . Cardiovascular adverse effects of doping in sports. Hellenic J Cardiol. 2012;53(6):447–457pmid:23178428
      OpenUrlPubMed
    43. ↵
      1. Faigenbaum AD,
      2. Kraemer WJ,
      3. Blimkie CJ, et al
      . Youth resistance training: updated position statement paper from the national strength and conditioning association. J Strength Cond Res. 2009;23(suppl 5):S60–S79pmid:19620931
      OpenUrlCrossRefPubMed
      1. McCambridge TM,
      2. Stricker PR; American Academy of Pediatrics Council on Sports Medicine and Fitness
      . Strength training by children and adolescents. Pediatrics. 2008;121(4):835–840pmid:18381549
      OpenUrlAbstract/FREE Full Text
      1. Jeukendrup A
      . A step towards personalized sports nutrition: carbohydrate intake during exercise. Sports Med. 2014;44(suppl 1):S25–S33pmid:24791914
      OpenUrlPubMed
    46. ↵
      1. US Anti-Doping Agency
      . What Sport Means in America: A Study of Sport’s Role in Society. Colorado Springs, CO: US Anti-Doping Agency; 2011. Available at: www.truesport.org/library/documents/about/what_sport_means_in_america/what_sport_means_in_america.pdf. Accessed September 23, 2015
    47. ↵
      1. Dunn M,
      2. Thomas JO,
      3. Swift W,
      4. Burns L
      . Elite athletes’ estimates of the prevalence of illicit drug use: evidence for the false consensus effect. Drug Alcohol Rev. 2012;31(1):27–32pmid:21450047
      OpenUrlCrossRefPubMed
    48. ↵
      1. Dunn M,
      2. Mazanov J,
      3. Sitharthan G
      . Predicting future anabolic-androgenic steroid use intentions with current substance use: findings from an internet-based survey. Clin J Sport Med. 2009;19(3):222–227pmid:19423975
      OpenUrlCrossRefPubMed
    49. ↵
      1. Levy S,
      2. Siqueira LM,
      3. Ammerman SD, et al; Committee on Substance Abuse
      . Testing for drugs of abuse in children and adolescents. Pediatrics. 2014;133(6). Available at: www.pediatrics.org/cgi/content/full/133/6/e1798pmid:24864184
      OpenUrlAbstract/FREE Full Text
    50. ↵
      1. Hagan JF,
      2. Shaw JS,
      3. Duncan P
      , eds. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. Elk Grove Village, IL: American Academy of Pediatrics; 2008
    51. ↵
      Bethel School District #43 v Fraser, 478 U.S. 675, 106 S. Ct. 3159; 92 L. Ed. 2d 549; 1986 U.S. LEXIS 139; 54 U.S.L.W. 5054 (1986). Available at: www.uscourts.gov/educational-resources/get-informed/supreme-court/landmark-supreme-court-cases-about-students.aspx. Accessed September 23, 2015
    52. ↵
      1. University Interscholastic League
      . 2013–2014 University Interscholastic League Anabolic Testing Report. Available at: https://www.uiltexas.org/health/info/2013-2014-uil-anabolic-steroid-testing-report. Accessed September 23, 2015
    53. ↵
      1. Levy S,
      2. Schizer M; Committee on Substance Abuse, American Academy of Pediatrics
      . Adolescent drug testing policies in schools. Pediatrics. 2015;135(4). Available at: www.pediatrics.org/cgi/content/full/135/4/e1107pmid:25825536
      OpenUrlAbstract/FREE Full Text
    54. ↵
      1. Goldberg L,
      2. Elliot DL,
      3. MacKinnon DP, et al
      . Outcomes of a prospective trial of student-athlete drug testing: the Student Athlete Testing Using Random Notification (SATURN) study. J Adolesc Health. 2007;41(5):421–429pmid:17950161
      OpenUrlCrossRefPubMed
    55. ↵
      1. Goulet C,
      2. Valois P,
      3. Buist A,
      4. Côté M
      . Predictors of the use of performance-enhancing substances by young athletes. Clin J Sport Med. 2010;20(4):243–248pmid:20606508
      OpenUrlCrossRefPubMed
    56. ↵
      1. Mears CJ,
      2. Knight JR; Council on School Health, American Academy of Pediatrics; Committee on Substance Abuse, American Academy of Pediatrics
      . The role of schools in combating illicit substance abuse. Pediatrics. 2007;120(6):1379–1384pmid:18055689
      OpenUrlAbstract/FREE Full Text
    57. ↵
      1. ATLAS and ATHENA Health Promotion and Substance Abuse Prevention
      . Available at: http://www.ohsu.edu/xd/education/schools/school-of-medicine/departments/clinical-departments/medicine/divisions/hpsm/research/atlas-and-athena-program.cfm. Accessed May 17, 2016
    58. ↵
      1. Kersey RD,
      2. Elliot DL,
      3. Goldberg L, et al; National Athletic Trainers’ Association
      . National Athletic Trainers’ Association position statement: anabolic-androgenic steroids. J Athl Train. 2012;47(5):567–588pmid:23068595
      OpenUrlPubMed
    59. ↵
      1. Partnership for Drug-Free Kids
      . Parent Talk Kit: What You Need to Know Before Talking to Your Child About Performance Enhancing Substances. New York, NY: Partnership for Drug-Free Kids; 2014. Available at: http://playhealthy.drugfree.org/uploads/resources_files/Play_Healthy_Parent_Talk_Kit_2014a.pdf. Accessed September 23, 2015
    View Abstract
    Back to top

    In this issue

    Pediatrics
    Vol. 138, Issue 1
    1 Jul 2016
    View this article with LENS
    Email Article
    Request Permissions
    Article Alerts
    Citation Tools
    Use of Performance-Enhancing Substances
    Michele LaBotz, Bernard A. Griesemer, COUNCIL ON SPORTS MEDICINE AND FITNESS
    Pediatrics Jul 2016, 138 (1) e20161300; DOI: 10.1542/peds.2016-1300
    del.icio.us logo Digg logo Reddit logo Twitter logo CiteULike logo Facebook logo Google logo Mendeley logo
    Print
    Download PDF
    Insight Alerts

    Jump to section

    Subjects