Piper Francis, 17, has been playing softball with lifelong friends since second grade, but last year, she noticed she was having difficulty breathing during practice. She saw multiple doctors who prescribed her asthma inhalers that didn’t help. She was heartbroken and was preparing to transition from an active player to team manager. Then, in early 2025, she was referred to the Exercise Respiratory Center at Cook Children’s – Prosper where her care team identified her breathing issue and helped her recover. Now, she’s back on the softball field and excited to play in her senior year.

Pulmonology Care at Cook Children’s 

John Robertson, M.D., pediatric pulmonologist at Cook Children’s Medical Center - Prosper, was Piper’s advocate, quickly figuring out what she needed to improve her breathing and help her continue playing softball.

“Almost every day last year, I would feel tightness in my chest and throat. It felt like something was blocking my airway,” Piper said. “I’d show up at softball practice and have to sit out through half of it. Now I’ve been able to go back to practice after seeing Dr. Robertson. He immediately recognized my problem and I felt better in less than a month!”

Piper was diagnosed with three conditions – exercise-induced asthma, exercise-induced laryngeal obstruction (EILO) and dysfunctional breathing. 

“The big challenge is that the problems look like each other,” Dr. Robertson said. “Asthma labels are really common and doctors may be right most of the time, but when asthma medications don’t work, there are no standard guidelines pointing at what to do next. The symptoms of these diagnoses – EILO and dysfunctional breathing – aren’t a problem of diseased tissues. They’re normal structures functioning abnormally.”

EILO happens when the vocal cords or neighboring structures collapse on inhalation during strenuous exercise.

Dysfunctional breathing occurs when someone breathes primarily with chest muscles instead of the diaphragm, resulting in inefficient, fast, shallow breaths rather than slower and deeper ones.

Finally Diagnosed at Cook Children’s Exercise Respiratory Center

Piper was diagnosed with EILO and dysfunctional breathing with testing at Cook Children’s Exercise Respiratory Center, which opened in 2023. The Exercise Respiratory Center diagnoses, treats and researches the causes of exercise-induced respiratory symptoms for older children, adolescents and young adults. Some of the many duties of the researchers at the Exercise Respiratory Center, Rebecca Brovina, MSHS, BSN, RN, CPN, and Andy Kreutzer, PhD, CSCS, LSSWB, include gathering data and presenting findings to share with other medical professionals about the diagnosis and treatment of exercise-induced respiratory symptoms.

It’s one of three centers in the U.S. that test continuous laryngoscopy during exercise (CLE) for children and the only center in Texas. During this test, Dr. Robertson will use a scope to view the patient’s voice box and vocal cords while the child exercises. Dr. Robertson was recently named a finalist for D CEO's 2025 Excellence in Healthcare Awards for Outstanding Healthcare Innovator.

“We just finished our 100th CLE test recently,” Dr. Robertson said. “We perform maximal exercise tests, try to provoke the symptoms under investigation while we are examining the patient's voice box with a camera and measuring their breathing efficiency, so we can see what is malfunctioning precisely when symptoms are present.”

Athletic patients like Piper are typically treated within four to six weeks, consisting of four to six visits of physical therapy and/or speech therapy. Piper only needed three visits.

“Piper is a very special person,” Dr. Robertson said. “She’s a dedicated athlete, driven and very competitive and her success story has been inspiring for all of us!”

Physical Therapy and Speech Therapy: Learning How to Breathe Again

Dr. Robertson’s Exercise Respiratory team includes a physical therapist and a speech therapist. Part of Piper’s care includes learning how to breathe again – through her diaphragm instead of her chest.

“Throughout PT and speech therapy, I’ve learned a lot of new breathing techniques,” Piper said. “My symptoms have drastically changed. I can make it through an entire practice now without struggling and missing practice trying to breathe. Learning how to breathe correctly helped me the most!”

Now, whenever Piper feels chest pain, throat tightness, lightheadedness, or breathing difficulties, she first notices if she’s overlooking her breathing techniques and then makes a conscious effort to stay aware and focus on her breathing.

Finding Answers and Hope for Others

Since Piper’s care with Dr. Robertson and the Exercise Respiratory team, her health has drastically changed.

“Emotionally, it makes me feel relieved,” Piper said. “I don’t have to worry about struggling at practice anymore and I can just show up and perform my best.”

Piper’s mom, Kristi Francis, noticed last year that she would come home from softball practice exhausted, had trouble breathing and it would take hours before she felt back to normal.

“It’s been a game changer for Piper,” Kristi said. “We went from doctor to doctor and no one really listened and everyone thought we were crazy. They didn’t believe her symptoms and we finally got to someone who knew exactly what to do.”

When to Seek Further Evaluation

“I feel like this condition needs to be more recognized and that a lot more people actually have it and just don’t know,” Piper said. 

General red flags for people to pay attention to and seek further evaluation:

1. If someone is labeled as having asthma and uses an inhaler, but still has lots of symptoms when the asthma treatment doesn’t help.
2. In EILO, there can be a symptom called stridor, which is exclusive to the voice box: stridor occurs when breathing in, usually as a loud, high-pitched sound that can be heard by others standing nearby. In asthma, wheezing happens during the breath out and is usually a quieter sound only noticed by the person experiencing the symptom.
3. Along with the symptoms above, experiencing dizziness and lightheadedness, passing out/coming close to passing out.

Finding the right diagnosis makes all the difference and can help athletes like Piper feel better, get back to competition and even breathe better than ever before.

But what is the healthiest way for young competitors to muscle up? If you are raising an athlete, chances are you’ve heard a coach tell your child to do just that. Bulk up. Gain weight. Get stronger. Improve your power.

The natural inclination of any driven young athlete can be to hit the weight room and add calories to pack on the pounds. But it’s not that cut and dry.

“When we tell a 14-year-old to bulk up, they’re immediately going to think that they need to start lifting heavier and heavier weights,” said Jacky Arrow, PT, DPT, SCS, COMT, Cook Children’s clinical coordinator of sports rehab. “They may start trying things they have seen others doing and that they may not really know how to do. Weightlifting is great, but it could lead to issues and injuries if it isn’t done appropriately, and done with supervision and the right technique.”

All Things Are Not Equal

Muscles aren’t one size fits all. Every sport and what it requires of the athlete and their body size, shape and structure is different. What football demands of a future Division-1 lineman isn’t the same as what baseball demands of a pitcher, or soccer demands of a goalie, or tennis demands of a pro.

“There’s an important need in all sports for a general level of physical preparedness,” said Savana Turner, ATC, a certified athletic trainer at Cook Children’s. “We need to move well, have good mobility in our joints, have good strength and good flexibility. Then, when we’re getting into the higher levels of sports, a sprinter needs a different level of power than maybe a baseball pitcher. They need to be working on very differentiated programs that have the same base level, but can be specialized more into strength versus power versus endurance, depending on what their sport requires.”

Things like age and genetics also factor into a kid’s ability to bulk up. A child’s body can only do so much until it reaches a certain maturity. While kids and teens can improve their performance in a given sport by learning how to most effectively use the muscles they have, it isn’t until they hit puberty that they can see a change in muscular size associated with their strength programming.

“No scientific evidence indicates that participation in a supervised resistance training program will stunt the growth of children or damage developing growth plates,” said Nicole Pitts, D.O., a sports medicine physician at Cook Children’s-Prosper. “Although there is no evidence-based minimum age for participation in a youth resistance training program, all participants should be able to accept directions and follow safety rules. Generally, when youth are ready for sports participation, approximately ages 7 or 8, they are ready for some type of resistance training as part of a well-rounded fitness program. Then, I would say, they can progress to heavier weight around puberty but should wait to do powerlifting or Olympic lifting until they reach skeletal maturity.”

For some, making a big jump in size just isn’t in the cards.

“Some kids are just not going to get big,” said Carolyn Mullins, PT, rehab services manager at Cook Children’s Medical Center. “It’s not in their genetic makeup, and they need to keep those things in mind and be safe about choices that they’re making. You can push and push but if your body’s not built to be a lineman, then your body just isn’t built to be a lineman, and there is not a safe way to do it.”

Before your athlete jumps into the weight room or adopts a diet plan, the most important thing to have in place is supervision. Lean on professionals to design a program that is appropriate for your child and considers their age, progression through puberty, body type and sport.

Know the end game, too, be it increased velocity for the pitcher or girth for the lineman. Is the goal to add weight or gain muscle? What is the definition of “bulking up” for your coach, trainer and sport? Are you looking for more upper body strength or lower body strength, and why? Understanding what you are trying to accomplish and having a plan supervised by a professional will help you reach your goal while minimizing your risk.

The Building Blocks for Bulk

You need three things to build muscle.

●     Strength and resistance exercises that challenge the muscle.

●     A well-balanced diet that includes muscle-feeding protein.

●     Time for muscle recovery and rest so that muscle fibers can rebuild, making you less prone to injury.

Dr. Pitts, who knows a thing or two about the needs of elite athletes as a former professional tennis player, recommends starting your muscle-building journey by using your own body weight as resistance. Once you’ve mastered that, you can progress to very light resistance using lower weights with high repetitions before puberty. As you get older, you can increase both of these.

A good muscle-building program will include both training and nutrition. Without adequate nutrition, you don’t have the building blocks to increase muscle strength and size. But the right nutrition without the right training and practice won’t get the job done either.

Food is Fuel

All calories are not equal when it comes to a well-balanced diet that promotes muscle growth. A diet full of sugary drinks, junk foods and fast food may help you pack on the pounds, but it can lead to fatigue and poor performance, even for kids who seem to have an endless well of energy.

“Our society has been greatly impacted by childhood and adult obesity, so general advice to ‘gain weight and bulk up’ can be very challenging to navigate,” said Rachel Hill, RD, CSO, LD, CNSC, a registered dietitian at Cook Children’s Medical Center. “Being an active teen does not eliminate the risk that comes with a weight that is too heavy for the child’s frame or eating a diet that far exceeds the body’s needs or is laden with junk foods. While the risks of eating a junk food diet may not be obvious to a teen at first glance, they are robbing their body of essential nutrients for optimal growth, development, function and performance.”

As a general rule, kids should eat a diet rich in whole foods that includes a mix of carbohydrates, protein and fat. Doing so will not only fuel your body with healthy, energizing calories but also give you the vitamins, minerals, fiber and other nutrients you need for peak performance. Once puberty hits, males often require more protein and females more iron.

“Athletes need about 1 to 1.4 grams of protein a day per kilogram of body weight to help with muscle building and repair,” Dr. Pitts said. “It’s a little bit more than their non-athletic peers. So for a 150-pound athlete, having about 80 grams of protein, or 20 extra grams of protein compared to someone else a day, is ideal. If you end up going beyond that, the body doesn't always utilize it. A lot of times athletes will take three times the amount of protein that they need a day.”

Beware of using supplements to add protein. This can actually add more protein than the teen body needs. Supplements also may contain substances like creatinine, which can cause renal failure if used improperly and is not recommended for teens, according to Dr. Pitts.

When it comes to powering the athlete, timing is key. What you eat before, during, and after activity helps fuel your performance and recovery.

“The foods we eat provide fuel for our bodies in the form of calories,” Hill said. “Calories come from three sources: carbohydrates, protein, and fat. While all three are important for a well-balanced diet, carbohydrates are most important prior to a workout to provide enough fuel for the workout. Without enough carbohydrates, the body defaults to breaking down muscle to fuel the workout. Incorporating a little bit of protein into the pre- and post-event snacks can also help protect muscle mass.”

Teen athletes should eat a meal or snack at least 30 minutes before and after exercise to fuel their performance and protect the hard-earned muscle mass they’ve built.

Take A Break

Allowing time for your muscles to rest and recover isn’t slacking, it’s actually muscle-building. If the muscle fibers broken down during activity aren’t given the chance to rebuild, you’ll actually interrupt the muscle-building process, end up losing mass and make yourself prone to fatigue-induced injury. If you are strength training, don’t work the same muscle group two days in a row. Put one to two days of rest in between. The American College of Sports Medicine recommends two to three non-consecutive days of strength training per week for teens.

Dr. Pitts also warns about specializing in a single sport too early. Branching out into other sports creates a well-rounded athlete with cross-trained muscles and skills. It also protects the athlete’s mind and body from burnout.

“Taking care of your body as a whole is really important and is a really difficult thing for a child or a teenage athlete to keep in mind,” Arrow said. “It’s that end-game mindset. Sleep. Drink water. Eat a well-balanced diet. Participate in a broad variety of activities. Taking time off from your sport and focusing on moving well over putting more weight on the bar is the key.”

The bottom line if your teen wants to be an athlete to be reckoned with? Train well. Eat healthy. Play hard. Rest. And, above all, enjoy the game!

Last night, NBC 5 Investigates released an enlightening report looking at the rates of concussions in North Texas districts. This report showed a much higher rate with more than 2,500 concussions reported in just 41 districts.

There are still a lot of misconceptions about concussions, what they are and what they might mean to your student athlete.

Here are 5 concussion MYTHS:

1. It was just a “mild” concussion.

Concussions are brain injuries, period.

One might classify a concussion as mild if symptoms were brief and not severe. However, you cannot predict whose symptoms will be severe based on the way the child was injured or even the symptoms right after the injury.

Even seemingly minor trauma can cause headaches and other symptoms for weeks.

2. If the child/athlete didn’t lose consciousness, it wasn’t a concussion.

Symptoms of concussion vary from child to child but passing out or blacking out are not required to make the diagnosis. Basically if a child has a fall or other injury that results in any neurologic symptoms, they can be diagnosed with a concussion.

Some examples of concussion symptoms are headache, nausea/vomiting, vision changes or problems with concentration and memory. Some of these symptoms may take time to develop, so it’s possible to diagnose a concussion a few days after the injury.

3. Concussions are only a problem for football players.

Almost all sports can cause concussions, including the cheerleaders on the sideline of the football games. Some other sports that are known to have higher incidents are soccer, baseball and softball. Other common causes are kids riding bikes and falling off playground equipment.

4. All concussions need either an MRI or CT of their head.

Most concussions can be diagnosed based on telling your doctor the story of the injury and the related symptoms along with a physical exam. Imaging is not necessary because a CT or MRI will most likely be normal even in the midst of a severe concussion.

Also remember that a CT of the head does not come without risk. While we should perform them when necessary, we should make sure we are not using them in situations where they will not provide useful information.

5. Don’t let your child sleep after a concussion.

Treatment of concussions is evolving. If you suspect your child has sustained a concussion, you should immediately seek medical attention and advice from a doctor about how you should treat your child’s symptoms.

There have been some changes in the treatment of concussions. First, we no longer require that you keep someone with a concussion awake for a set period of time. In fact, after their evaluation, the doctor may recommend that you allow them to sleep in order to help their brain heal. Your doctor might also prescribe some time away from TVs and other screens, school or homework or other activities that might cause their brain to work harder.

Concussions are much more common than we previously thought. I believe that the UIL will make changes to better track the risk of concussions for our high school athletes, which will hopefully lead to better ways of evaluating and treating concussions. In the mean time, don’t buy these common concussion myths.

Unfortunately, it’s also a troubling trend among today’s high school athletes.

Cook Children’s pediatrician David H. Goff, M.D., FAAP, calls overstressed, busy children a huge problem – both in the classroom and on the playing field. In his Denton office, Dr. Goff sees patients who suffer from a variety of symptoms like chronic abdominal pain, anxiety and depression.

“I see this over and over. I look in the child’s eyes. They are exhausted. I say to the parents, ‘You need to cut back,’” Dr. Goff said. “And it is amazing to me. They say, ‘We can’t. No way. We have a tournament this weekend.’ For any successes we have, we have 100 more burnouts.”

The American Academy of Pediatrics agrees with Dr. Goff. A group of eight organizations, including the AAP, released a consensus statement regarding their concern with today’s high school athlete.

The AAP states, “Student athletes report higher rates of sleep disturbances, loss of appetite, mood disturbances, short tempers and inability to concentrate than non-athletes.”

The recommendations focused on the importance of educating students, parents and coaches on mental disorders in student-athletes; the stress involved with today’s athletes and ways to monitor their behavior.

Concerns of the AAP included the injuries and stress related to student athletes training year round, which doesn’t give them time to rest and recover.

The AAP said these athletes also face stress from poor performance on the playing field, injuries, concerns about getting cut from the team and trouble keeping up with school work, along with their extracurricular activities.

Because of the stress involved, student-athletes may suffer from “a pattern of lack of sleep and under-recovery” and chronic fatigue that puts him or her at risk for anxiety and depression. Other issues include:

• Physical (Physical conditioning, injuries, environmental conditions)
• Mental (Game strategy, meeting coaches’ expectations, attention from media and fellow students, time spent in sport, community-service requirements, and less personal and family time)
• Academic (classes, study time, projects, papers, examinations, attaining and maintaining the required grade point average to remain on the team, and earning and maintaining a collegiate or academic scholarship).

David Gray, M.D., medical director of Cook Children’s Orthopedics and SPORTS, agrees with Dr. Goff that too much activity can simply be harmful to a young person.

With the advent of select sports and recreational leagues, Dr. Gray said children now play the same sport year round without getting a break from those activities. He wants young athletes to have variation in their activities. If not, the repetitive nature of the same sport creates stress and strain especially on growing bones.

Dr. Gray and his colleagues see children who never have a break during the year sometimes playing on two or three different teams during the same season. He said it’s too much stress on their growing skeleton, causing muscle aches, strains and pain.

Both Dr. Gray and Dr. Goff stress children, especially before they reach high school, should focus on participating in several different sports to prevent using the same muscles year round. They say it also helps the child avoid getting burned out on that specific sport.

“For kids, sports are great and you learn a lot from them, but they should be fun,” Dr. Gray said. “Kids need to enjoy them too. You don’t really want a 12 or 13 year old performing to the point where they are having injuries that could actually impact them as an adult.”

Dr. Goff admits this subject quickly places him on his soapbox. But it’s because he sees so many of his patients facing stress and are simply not happy.

He sees them come in with dark circles under their eyes and behind closed doors and just one-on-one with him, they admit to a different story than what they have been telling to their parents.

Far too often, Dr. Goff hears the regrets of parents, but only when it’s too late. The child has gone off to college and the parent wishes they had taken a trip to the Grand Canyon with their family, instead of racing off to another game.

“I ask the parents to leave the room so I can talk to the child,” Dr. Goff said. “I ask, ‘Do you really want to do this?” They say, ‘No I’m tired.”

The scary part of this story is that far too often the parents are trying to do what’s best for their child, but in reality they are doing harm.

Dr. Gray said he is beginning to see injuries in children as young as 8 years old with ACL injuries. Injuries that were once thought not to happen until children were much older.

“Another problem is that the really good, young kids are getting left behind,” Dr. Gray said. “They are burned out because they are pegged to be the superstar and they get over worked, over trained and over pushed. Some get burned out and pushed to the wayside and other kids, who were not as big, catch up by the time they are in middle school. They have more passion and they are not burned out. And they pass them by.”

Both Dr. Gray and Dr. Goff also see phantom injuries – muscle aches or headaches. Anatomically there seems to be nothing wrong with the child. In reality it’s the child hinting he or she needs a break.

So what should a parent do? Here’s a start:

• During the year give the child down time and a chance to recuperate. This is the case physically for sports and mentally for school.

• Vary the child’s routine to avoid burnout

• Give your children an opportunity to tell you if they are enjoying themselves.

“It’s easy to succumb to parental peer pressure,” Dr. Gray said. “Parents are afraid if they don’t do something their child will be left behind. What’s most important is that your children enjoy sports, or enjoy their activities and has a good mental outlook on life. It’s hard for parents to not live vicariously through their children. It’s a hard lesson for parents. You want the best for your child and want your child to be successful. But sometimes less is more.”

Even highly competitive and high intensity training can be healthy, but can it become unhealthy?

One of the dangers of intense training can be a lack of food intake to keep up with the demands of the sport. Have you seen the pictures of food in front of Olympic swimmers? They often eat up to 10,000 calories per day. Yet, our young teenage athletes, in an attempt to manage their weight or achieve a particular body image sometimes cut calories to levels even below their less active peers.

This is when their health could be in danger.

Certain sports may put athletes at higher risk to engaging in unhealthy behaviors. Think about those where body image plays a large role such as dance or gymnastics. Those competing in sports that classify participants based on weight class can also be at risk. Even participants in sports that don’t fall into these categories can have pressure put on them to “lose a few pounds” in order to improve.

These problems can arise in boys and girls, but girls can have particular health consequences that need to be considered.

What is the female athlete triad?

• Energy deficiency (not eating enough food)
• Loss of periods
• Low bone mass (osteoporosis)

Energy deficiency -This can be the result of simply not consuming enough food or it can be a conscious method to decrease calorie intake for weight loss. In more severe cases it can be the results of an abnormal body image or an eating disorder.

Loss of periods -The calorie deficiency can lead to decreased production of hormones that help periods to be regular. This can lead to missed periods or for periods to stop altogether. Missed periods are often the symptom that brings attention to the overall problem. Because of this, I recommend you check in with your athletes intermittently about their periods. Despite the weird and embarrassed look on faces (it translates, “Mom, can you believe he’s asking this?”), I ask at every check-up.

Low bone mass - Decreased hormones and intake of calcium can lead to thinning of the bones. When severe, this can cause stress fractures, which are fractures that occur with very little or no trauma. In addition, girls are supposed to building up bone density in this time frame and the long term implications of not doing so could have severe consequences.

What can you do?

Pay attention to your athletes and their eating habits.

If you see any of the following, set up a visit with your pediatrician to address your concerns:

1. Weight loss or disorder eating habits.
2. Irregular periods or no periods.
3. Injuries from mild activity or that tend to linger.

Together you and your pediatrician can gather a team around your athlete to ensure their health for now and into the future.

Some potential members of the team could include a:

1. Pediatrician
2. Dietician
3. Counselor
4. Coach or trainer