Over the last decade, there has been a steady rise in the number of young children participating in endurance running events. The voices in the debate over the safety of long-distance running in this age group continue to increase. More than ever, pediatricians are being asked to advise parents and their children on whether training and participating in full and half marathons is safe. Pediatricians should be well informed and able to discuss the potential risks and benefits when advising families.
A 9-year-old girl and her mother present to the office to discuss the girl's upcoming training for a half marathon. The mother inquires about how to prevent injuries in her child while training for this event. Can her daughter train safely for a half marathon? Are running programs safe for young athletes? What is “too much” in terms of running for a child her daughter's age?
Prepubescent children have been participating in marathons for decades, yet there exists little concrete evidence on their experiences (positive or negative) during training and while running in the actual event.1,2 Supporters of long-distance running in young children cite the general lack of physical activity in youth. Children who participate in long-distance running can develop discipline, build self-esteem, and achieve a high level of fitness.3–5 Detractors point toward the ability to achieve a high level of fitness with significantly less running, not to mention the risk of overuse injuries associated with training volume, the pitfalls of sports specialization at such an early age, and potential for burnout given the significant time investment.3
Health Risks and Potential Injuries
A parent that comes to the pediatrician to discuss half-marathon training is likely seeking information about health risks, which include concerns about musculoskeletal, endocrinologic, hematologic, and psychologic issues. The most common musculoskeletal injuries in children are overuse injuries, including but not limited to Osgood-Schlatter syndrome, patellofemoral pain syndrome, stress fractures, and medial tibial stress syndrome (shin splints).4,6,7 Some studies have estimated the prevalence of overuse injuries in youth running to be as high as 68%.8 These injuries can occur secondary to anatomic issues (ie, muscle tightness, foot anatomy), ill-fitting equipment (ie, inappropriate footwear), improper rehabilitation from a previous injury, and/or biomechanical problems (ie, stride length or gait).9 Identifying and addressing the causes of such injuries through physical therapy, cross training, and relative rest can provide the most successful treatments. Injections and surgery are rarely needed.
Stress fractures follow a fairly predictable course of increasing pain even with decreasing levels of physical exertion. If a young athlete has a stress fracture, then they usually have pain with activities of daily living. Menstrual dysfunction and female gender have been identified as risk factors for stress fractures. High-risk sites include the femoral neck, patella, anterior tibia, medial malleolus, talus, tarsal navicular, fifth metatarsal, and the sesamoids.6,7,10 Initially, a plain X-ray of the affected body part should be performed. However, it may not reveal a stress fracture until 3 to 4 weeks after the pain begins. The second-line test would include either a magnetic resonance imaging or bone scan depending on the site of injury and available local resources. Early identification, relative rest, correction of the underlying etiologies, and a gradual return to activity are the best strategies for both prevention and treatment.
Research suggests that children playing sports in the midst of growth spurts are more prone to injury.4,6,7 The growth plate and articular cartilage are at risk of injury from repetitive loading and shear forces, particularly at the proximal tibia and distal femur in runners. Young children and their parents often have trouble gauging the seriousness of these various injuries, and there can be pressure from parents and coaches for the young athlete to continue to practice and perform despite pain. Pain must be absent during daily life activities as a primary standard for starting a gradual progressive return to the running program.
Intensive physical exercise, inadequate nutrition, and low body fat have been frequently attributed to delayed menses in young girls. This poor nutrition can exacerbate iron deficiency that may already be present in a menstruating adolescent girl. Prolonged amenorrhea increases the risk of stress fractures and decreased bone density due to decreased circulating levels of estrogen and diminished bone mineralization.11,12
Is Waiting Until After Puberty Better?
There is evidence to suggest that young athletes who wait until after puberty to specialize in a sport have fewer injuries, perform more consistently, and play sports for more years than those who specialize at younger than age 13 years. Half-marathon training can be quite intense compared to training for other sports because of the weekly mileage required to build up race-ready stamina. The young athlete may be running for several hours a day 4 to 5 days a week.
Studies have shown that youth who train more than 16 hours a week are at increased risk of injury that will require medical attention.13,14 Others have reported that training more hours per week than the age of the child in years is an injury risk factor.15 Half-marathon training in a prepubescent child could easily exceed these numbers in the mid to latter stages of training. Psychosocially, long hours of training may be challenging for children training by themselves or only with adults. Adults may be training with different goals in mind (ie, competition, weight loss). In children, the potential for burnout becomes a real possibility.4
Sport or Fitness?
Half-marathon running is not typically categorized as an organized sport. The benefits of organized sports include learning sports-specific skills, proper technique, and team building under good coaching tutelage.16 Half-marathon running, although it could possess these benefits, can end up being a parent-driven activity (ie, the child is half-marathon training with a parent who is a runner but not necessarily a coach or knowledgeable about running, technique, and potential injury pitfalls). Other observers have cited concern for heat illness, including heat exhaustion or heat stroke, which can occur during training for any sport.17 Adequate hydration, proper clothing, and running under safe weather conditions become critical preventive factors in keeping children safe.
If the goal of encouraging a child to run a half marathon is fitness, the strongest argument against running a half marathon is that fitness can be achieved with much shorter running distances and without all the risks associated with long-distance running. Herein lies one of the toughest questions: Is long-distance running inherently less safe than other sports? The evidence does not seem to suggest that full marathons or half marathons are not safe. Arguably, a young athlete can be injured in contact/collision sports such as basketball and soccer or noncontact sports like track and gymnastics. Education in proper technique, training duration, rest and recovery, and proper rehabilitation of a previous injury are the most important tools for injury prevention.
Selecting Proper Footwear
Running requires a minimal amount of special equipment—proper footwear. Running shoes should be selected based on the athlete's foot type.18 A wet foot test can be performed at home to determine the type of foot the athlete has and match it with the proper shoe type.18 Running shoes should also be changed every 300 to 500 miles or every 6 months, whichever comes first.
Anyone preparing to run a half or full marathon, including young athletes should participate in a training program specifically for running. However, questions about whether young athletes should be encouraged to participate in these running endurance events still linger. The decision to participate should be based on intent—the intent of the young athlete, not parents or coaches. Young athletes who participate in half-marathon training must want to do so for themselves.4 The emphasis should be squarely on the joy of running, the completion of the race, and not necessarily competition. Once competitiveness enters the picture, the safety boundaries for the young athlete can become blurred. The optimal way for a prepubescent athlete to train for a half marathon would be with other prepubescent friends who share the same goal as well as have parents who are supportive and not pushing their own agenda.
Determining Readiness to Participate
The real question is how young is too young? Sports readiness is a question best answered by a medical professional who understands the developmental stages of growth and by parents who know their children well.6,7 The child's socialization skills, motivation to run, knowledge about running, and running skill are the most important variables in assessing readiness to participate.
A 9-year-old can safely participate in a half marathon with the proper training, parental attention to health and well-being, and keen awareness of the potential for overuse injury and burnout. The 9-year-old should be able to discontinue training at any time for any reason (ie, wants to spend more time playing other sports, hanging out with friends, has pain when running, isn't having fun anymore).
Young children can participate in half or full marathons under the close supervision of parents, coaches, and physicians. This ensures proper attention to mental and physical fatigue, proper technique, adequate rest periods, appropriate footwear, and adequate medical evaluation of potential injuries. A running program should gradually build up the child's stamina and should be individualized to each child. If a child is struggling with the prescribed plan, then parents and coaches should reevaluate the current plan and allow the child to progress at a new pace that is better suited to that child's needs.
The goal of long-distance running in a young child should be the enjoyment of running and physical fitness. These goals should be articulated by the child athlete, not by the parent. Competition should not enter into the equation.
Every child runner should have an examination by a personal physician prior to initiating training. This is an excellent time for preparticipatory counseling and health evaluation, ensuring that any lingering injuries are properly rehabilitated before training begins. Laboratory studies or imaging should be done as indicated.
For every training event, pre- and post-discussions with the child, parents, and training partners should be done to screen for injuries and psychologic distress. Periodic physician visits are not unreasonable and after any injury the physician should be consulted immediately. When children want to stop training, they should be allowed to without any punishment or resistance.
During the race, special attention should be given to the risks of dehydration and heat stress. Six to 12 months after the race, growth and development should be closely monitored. A period of rest and recuperation should immediately follow the race, and the young athlete should be given space/opportunity to participate in other sports.
- American Academy of Pediatrics Committee on Sports Medicine and Fitness. Risks in distance running for children. Pediatrics. 1990;86(5):799–800.
- Roberts WO, Nicholson WG. Youth marathon runners and race day medical risk over 26 years. Clin J Sport Med. 2010;20(4):318–321. doi:10.1097/JSM.0b013e3181e6301d [CrossRef]
- Rice SG, Waniewski SAmerican Academy of Pediatrics (AAP) Committee on Sports Medicine and FitnessInternational Marathon Medical Directors Association (IMMDA). Children and marathoning: how young is too young?Clin J Sport Med. 2003;13:369–373. doi:10.1097/00042752-200311000-00006 [CrossRef]
- Brenner JSAmerican Academy of Pediatrics Council on Sports Medicine and Fitness. Overuse injuries, overtraining, and burnout in child and adolescent athletes. Pediatrics. 2007;119(6):1242–1245. doi:10.1542/peds.2007-0887 [CrossRef]
- Council on Sports Medicine and FitnessCouncil on School Health. Active healthy living: prevention of childhood obesity through increased physical activity. Pediatrics. 2006;117(5):1834–1842. doi:10.1542/peds.2006-0472 [CrossRef]
- DiFiori JP, Benjamin HJ, Brenner JS, et al. Overuse injuries and burnout in youth sports: a position statement from the American Medical Society for Sports Medicine. Br J Sports Med. 2014;48(4):287–288. doi:10.1136/bjsports-2013-093299 [CrossRef]
- DiFiori JP, Benjamin HJ, Brenner JS, et al. Overuse injuries and burnout in youth sports: a position statement from the American Medical Society for Sports Medicine. Br J Sport Med. 2014;48(4):287–288. doi:10.1136/bjsports-2013-093299 [CrossRef]
- Tenforde AS, Sayres LC, McCurdy ML, Collado H, Sainani KL, Fredericson FM. Overuse injuries in high school runners: lifetime prevalence and prevention strategies. PM R. 2011;3(2):125–131. doi:10.1016/j.pmrj.2010.09.009 [CrossRef]
- Wen DY. Risk factors for overuse injuries in runners. Curr Sports Med Rep. 2007;6(5):307–313.
- Niemeyer P, Weinberg A, Schmitt H, Kreuz PC, Ewerbeck V, Kasten P. Stress fractures in the juvenile skeletal system. Int J Sports Med. 2006;27(3):242–249. doi:10.1055/s-2005-865649 [CrossRef]
- Cobb KL, Bachrach LK, Greendale G, et al. Disordered eating, menstrual irregularity, and bone mineral density in female runners. Med Sci Sports Exerc. 2003;35(5):711–719. doi:10.1249/01.MSS.0000064935.68277.E7 [CrossRef]
- De Souza MJ, Nattiv A, Joy E, et al. 2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad: 1st International Conference held in San Francisco, California, May 2012 and 2nd International Conference held in Indianapolis, Indiana, May 2013. Br J Sports Med. 2014;48(4):289. doi:10.1136/bjsports-2013-093218 [CrossRef]
- Loud KJ, Gordon CM, Micheli LJ, Field AE. Correlates of stress fractures among preadolescent and adolescent girls. Pediatrics. 2005;115(4):e399–e406. doi:10.1542/peds.2004-1868 [CrossRef]
- Rose MS, Emery CA, Meeuwisse WH. Sociodemographic predictors of sport injury in adolescents. Med Sci Sports Exerc. 2008;40(3):444–450. doi:10.1249/MSS.0b013e31815ce61a [CrossRef]
- Jayanthi NA, LaBella CR, Fischer D, Pasulka J, Dugas LR. Sports-specialized intensive training and the risk of injury in young athletes: a clinical case-control study. Am J Sports Med. 2015;43(4):794–801. doi:10.1177/0363546514567298 [CrossRef]
- Washington RL, Bernhardt DT, Gomez J, et al. Organized sports for children and preadolescents. Pediatrics. 2001;107(6):1459–1462. doi:10.1542/peds.107.6.1459 [CrossRef]
- Intensive training and sports specialization in young athletes. American Academy of Pediatrics Committee on Sports Medicine and Fitness. Pediatrics. 2000;106(1):154–157.
- Children's Hospital of The King's Daughters. Selecting the right athletic shoe. http://www.chkd.org/uploadedFiles/Documents/Programs_and_Clinics/athleticshoebrochure.pdf. Accessed February 18, 2016.