Heat illness during sports practice or competition is among the leading causes of death in the U.S. for high school athletes, according to the Centers for Disease Control and Prevention (CDC). Scorching summer sun and high temperatures put athletes at increased risk for heat illness, no matter their fitness level. 

Coaches and directors of marching bands are currently conducting practices, rehearsals and scrimmages ahead of football season. This summer, North Texas experienced lengthy stretches of triple-digit temperatures and drought. Rainy days have tampered down the heat, but the humidity is still high.

Students’ primary preparation begins with hydration – not just during and after practice. Drinking water and clear liquids must begin hours, even a day, before the exercise and exertion, said Jason Terk, M.D. of Cook Children’s Pediatrics Keller Parkway.

“If you're not dealing with a full tank, you are not going to be able to catch up or keep up,” Dr. Terk said. “Those leading the practices must also build in enough breaks for rest, shade and hydration.”

Keeping pace with science and research, the University Interscholastic League (UIL) sets guidelines around heat stress and athletic participation for high schools. Their recommendations follow research from the American Academy of Pediatrics Committee on Sports Medicine. UIL now recommends water availability for athletes in unlimited quantities. Cold water is best. Additionally, practice schedules should include 10-minute water breaks for every 20-30 minutes of exercise in the heat.

Dr. Terk is a self-proclaimed marching band nerd and is an unofficial chaperone for Keller High School’s marching band.

Guidelines Make Sense

“In 15 years of doing this, the last nine of them at Keller High School, I have no reported heat-related emergencies,” said Ryan Heath, director of the marching band.

There are two parts to Heath’s preparation for marching season, the music-only rehearsals indoors and the music-plus-marching outside.

“Our district has great guidelines related to temperatures and that dictates what our hours are,” Heath said. “We work to schedule the outdoor part in early morning or in the evening before sundown.”  

Keller Independent School District bases decisions on the National Weather Service’s Wet Bulb Globe Temperature Forecast. Its measurements can help manage workload in direct sunlight and capture temperature, humidity, wind speed, sun angle, and cloud cover (solar radiation). Many of us are more familiar with the “heat index” that only measures temperature and humidity, and does so in the shade.  

Heath starts the discussion with his students in the spring, about summer training for the fall marching band season. When rehearsals get underway, he expects students to have done enough summer activity so they can complete a one-mile run in 10 minutes. Heath says the measurement ensures band students have the cardiovascular endurance required, to play an instrument successfully and march simultaneously. He came up with it after consulting medical professionals and other  experts.

“We don’t have a certain training regimen,” Heath said. “But this is an athletic activity as much as sports and my expectation of participants is they maintain good physical health and stay hydrated.”

For safety precautions, he requires students to have a hat, sunglasses, a gallon of water, and sunscreen when they report for outdoor marching rehearsals. Without those, they cannot participate. He also says, during the first weeks of marching practice many parents show up with extra pop-up tents, ice packs and more water to help monitor students’ response to the heat. Many of the parents are doctors, nurses, nurse practitioners and others with professional expertise.   

Ease Into Practice  

“I played high school football and we practiced for three hours with one water break,” said Daniel Guzman, M.D., pediatric emergency medicine physician with Cook Children’s Medical Center. “I’m happy to see that we have advanced from the archaic ‘it will toughen you up’ to water breaks are important for players’ safety.”

Dr. Guzman’s youth sports career included summer practices in South Texas. He knows now just how dangerous it was and how preventable heat emergencies are.

“Exertional heat illness is one of the leading causes of death each year. Parents need to be aware and informed about their children’s practice schedules and the team’s policy on modifications of practice depending on the level of heat that day,” Dr. Guzman said. “At what temperatures do we modify our practice schedule?  It is within a parents’ right to know what these policies are and what are children being taught about rest and hydration to keep them safe.”

Dr. Guzman says coaches and band directors can help student athletes by acclimatizing to heat during the first seven to 14 days of practice. He says athletes can become more heat tolerant, but are never out of danger. Coaches should be careful and watch closely, while athletes need to self-restrict activity if they begin feeling badly – the sooner the better – to avoid emergencies.

“It’s important to be careful when pushing these young athletes to their limit and be mindful that most kids won’t say they feel bad or need to stop,” Dr. Guzman said.

Early Warnings

What are the earliest signs of heat illness? Dr. Guzman says it usually begins with muscle cramps, lightheadedness, headache, abdominal cramps and nausea. If you ignore these early signs, your condition could become emergent quickly. If you are too sweaty and looking pale, Dr. Guzman says that means it is time to get in the shade and drink something with electrolytes, like a chilled sports drink, to replace salts. It’s really important to treat the symptoms quickly, especially if the athlete is confused.

The color of urine is a good monitor for sufficient hydration. Dr. Guzman says it should be clear and not dark. If urine begins to look brown, red or tea-colored, there could be serious issues underway, like the medical condition called rhabdomyolysis (rhabdo). Rhabdo occurs when injured muscle tissue breaks down rapidly and releases proteins and electrolytes into the bloodstream. In large amounts, the substances can damage kidneys and other organs, cause rapid heart rate and even death.  

“The process makes the blood sluggish. Everything just aches and patients often say it’s too painful to move, they have achiness everywhere, flu-like discomfort,” Dr. Guzman said. “Kids can complain of feeling sluggish and weak. They should skip practice if this occurs and seek medical attention.”

Athletes that have dark-colored urine with or without any other symptoms should consider it a significant cause for concern. Blood tests can measure the level of substances released into the blood stream to diagnose rhabdo. One measurement important to Dr. Guzman is creatine kinase (CK). Normal ranges can vary among patient populations. Generally, he wants to see it under 300-350 micrograms per liter (mg/L). In the emergency department, he has seen patients whose CK is 1,000-2,000 mg/L range and he recalls one athlete with over 10,000 mg/L.

“The treatment is to continue IV hydration two times the normal amount until the patient feels better and the creatine kinase begins to decrease to normal levels,” Dr. Guzman said “Big muscular kids are the ones that concern us the most. Working out vigorously can break down all that muscle and create a dangerous situation.”

Avoiding heat illness among sport and marching-band athletes is a group effort among coaches, band directors, parents and kids. Respecting any outdoor activity for the possibilities and concerns related to heat stress is vital to the safety of student participants. Be cool this summer – literally!

Early Signs of Heat Stress

• Muscle cramps
• Lightheadedness
• Headache
• Abdominal cramps
• Nausea

Reminders for Athletes and Parents

• Monitor your body’s need for water or cooling breaks.
• Avoid worrying about being the ‘weak link.’
• It is okay to say, “I can't go anymore.”

RELATED: The Facts About Fainting in Children (checkupnewsroom.com)

Strength:  As these athletes push themselves to achieve the lifting goals set by coaches, is their form being supervised by someone trained to observe any breakdowns?  Complex lifts such as cleans, snatch, push-jerks, etc. put enormous strain on the athlete’s muscles, especially when they are younger and still developing, but if their form is poor it also makes them susceptible to back, shoulder, knee and neck injuries. Often the athlete lacks the core strength and stability to provide a solid foundation so that the body can move correctly. Core strengthening should be an integrated part of every strengthening program. Unfortunately, many of our athletes are never taught to control their core in basic sitting and standing postures, but yet we expect that they will somehow find their core while in the weight room or on the field. If you think core strengthening is all about abs, then you are missing the bigger picture.

Conditioning/ nutrition/ hydration: Cardiovascular conditioning is often an area that coaches hit pretty hard in the offseason, and most athletes have been working on some kind of conditioning program. However, the nutrition and hydration components of this area are often over-looked. Understanding how to fuel your body for peak performance is just as important as knowing how to perform the activity. Working with a nutrition/dietitian specialist can give your athlete the tools needed to unlock their full potential.

Flexibility: This is one of the most overlooked areas of a good training program for a football player getting ready for middle or high school ball. There is nothing glorious about stretching. There is also nothing glorious about missing a majority of the season while sitting on the bench due to a pulled hamstring. Flexibility training is about preparing the body to perform.  Dynamic stretching (moving stretches) prepares the body for immediate performance and should be used before any type of physical activity. Static stretching (prolonged holds) help prepare the body for tomorrow’s workout and promotes having the muscle length needed to achieve the greatest power. Use of a foam roller can also help improve flexibility by preparing the muscles for stretching.

Neuromuscular control: Why is it that the pros make it look so easy?  The ability to cut-back, stop-start, and change directions centers on the way an athlete’s brain can control the body. A physical therapist or trained professional can use any number of functional movement assessments to see how the body is moving and recommend corrective exercises and/or cues to improve these patterns. Learning the best patterns means the athlete can generate more power, more quickly, and in more directions. The best movement patterns also keep the body in the best alignment, and less likely to become injured.

Overtraining: The AAOS also recommends avoiding the pressure that is now exerted on many young athletes to over-train. Listen to your body and decrease training time and intensity if pain or discomfort develops.

See a physician if you begin having pain. This will reduce the risk of injury and help avoid “burn-out.”

Related links:

• Football injury prevention
• SPORTS resources
• Does your child play one sport?
• 9 ways to prevent injuries in young athletes
• Cheerleader injuries
• Top 10 questions parents have about sports injuries
• Young athlete's injury prevention guide
• Strength training in children/adolescents (5-15 years)
• Rise of overuse injuries in school-age athletes
• The basics of sports injury prevention for kids
• When growing pains are not growing pains
• Preventing children's sports injuries

About the author:

John Stanley, a physical therapist and SPORTS Rehab Clinical Coordinator at Cook Children's. The Cook Children's Sports Performance Orthopedic Rehab Team Specialists (SPORTS) program offers care to children and adolescents with orthopedic or sports-related injuries.