Heat Illness: How to recognize it in young athletes

By Dev K. Mishra, M.D.

I am often asked this time of year about some strategies for coaches and parents to recognize heat illness, and for some strategies to manage the young athlete. With that in mind let’s review some basic principles.

“Heat Illness” is a broad term used for a range of problems such as dehydration, cramping, dizziness, heat exhaustion and a very serious problem called heat stroke.

Young athletes are at a higher risk than adults for developing heat illnesses. Children absorb heat faster than adults, they don’t sweat as much (sweat helps the body cool), they take longer to get conditioned to exercising in warmer weather and often they don’t feel the need to drink fluids before or during exercise.

Recognizing Possible Heat Illness
Most young athletes will first start to show signs of heat-related illness through dehydration. The athlete may come off the field complaining of being tired, having leg cramps or feeling light-headed. On a hot day, be suspicious of the athletes with poor performance. They might not tell you anything -- be alert.

You might see signs of decreased performance, more fatigue than typical, they may be irritable. In more severe cases there may be nausea and headache. From the coach and parent’s perspective you’ll often need to be suspicious and watch for these signs on a hot day.

Basic Sideline Management for Heat Illness
* Get the athlete off the field and let her lie down in a cool, shaded place.

• Elevate the legs above the level of the head.

• Provide a sports drink (not carbonated, no caffeine).

• Loosen any tight-fitting clothing and remove socks.

• If the player doesn’t start to feel better within 10-15 minutes, seek medical help.

• Prevent future dehydration with a good fluid management strategy

Warning Signs
Young athletes should respond within 10-15 minutes from re-hydrating. You should see them “perk up” and get back toward their normal attitude and appearance. If an athlete does not improve, it may signal more severe dehydration and they should be evaluated in the emergency department of the local hospital.

“Heat Stroke” is a medical emergency. In heat stroke, the athlete will have very hot skin that can be wet or dry, a change in normal behavior (confused, irritable), vomiting, and even seizures or loss of consciousness; the athlete will look in obvious trouble. If you have any suspicion of this, call local emergency services or 911 immediately.

If you have called for emergency help, start cooling the athlete by applying ice packs to the armpits, groin, or neck. If ice is not available, squirt cold water over the head and trunk.

Play or Sit Out?
Once the athlete suffering from dehydration and mild heat illness has started to re-hydrate with fluids, he should return to his normal appearance and attitude in 10-15 minutes and with proper fluids should be able to return to play later that day.

If the athlete has not fully recovered, it may signal a more significant problem and a physician should be consulted before the athlete returns to play.

Key Points
• A good hydration strategy will go a long way toward minimizing the chance of heat illness.
• A young athlete with suspected heat illness will typically respond to cooling and re-hydration in around 15 minutes.
• Beware of hot skin. This is a possible sign of heat stroke, and is a medical emergency.

(Dr. Dev K. Mishra, a Clinical Assistant Professor of orthopedic surgery at Stanford University, is the creator of the online injury-recognition course, now a requirement for US Club Soccer coaches and staff members. Mishra writes about injury management at Blog, where this article first appeared. It has also previously appeared in the Youth Soccer Insider.)

13 comments about "Heat Illness: How to recognize it in young athletes".
  1. Nick Daverese, June 7, 2017 at 3:33 p.m.

    Got this from Jim Gordon on 2009

    Hydration: Preparation and Warning Signs
    Forget about every other question that you have about nutrition until you’ve
    figured out how to stay hydrated. Being smart about hydration can separate
    good performance from great performance.

    You are mostly water. In fact, if you took the water out of a 180-pound lean
    body, there would be about 55 pounds left. Because your muscles, your brain,
    your blood and sweat are mostly water, your body doesn’t work like it should
    when it is not properly hydrated. You don’t think as clearly, your endurance
    is compromised and your heart works harder.

    When you’re severely dehydrated, sweating stops and your body overheats. The
    result is fatigue, weakness, dizziness, and collapse, or worse. In fact,
    every year, deaths in young healthy athletes are linked to severe dehydration.

    Sweat It Out
    Sometimes you don’t even see sweat, like when you swim. But you sweat
    whenever your body heats up from working out. Sweat is your body’s cooling
    system. Evaporation of sweat from your skin cools you down.

    When you sweat, you lose fluid from your body. That fluid must be replaced,
    and replacing fluids takes a plan.

    Dehydration: A shortage of fluids in the body.

    Don’t Rely on Thirst
    You might be thinking, “What’s the big deal? Won’t drinking when I’m thirsty
    guarantee that I’m hydrated?” Surprisingly, no. During exercise, for reasons
    not totally understood, humans don’t drink enough to prevent dehydration.
    You need to drink before you’re thirsty and keep drinking after you no
    longer feel thirsty..

  2. Nick Daverese, June 7, 2017 at 3:34 p.m.

    Part 2
    Drink It In
    Forget about the old rule of drinking 8 glasses of water per day. You
    probably need more than that on most days. Counting how many glasses you
    drink is only one way of keeping track of what you need. A better way of
    making sure you’re hydrated is to check your body weight before and after
    practice. For accuracy, weigh yourself in minimal clothing if there’s
    privacy, and afterwards, change out of the sweaty clothing before you weigh.
    The weight lost during practice or competition is not fat, it’s fluid loss.

    One pint of fluid weighs one pound. To replace the fluid, drink one pint of
    fluid (Gatorade or water) for every pound you lost. (One pint = 16 ounces =
    500 ml = ½ liter). It is critical to replace this as quickly as possible.
    Before your next workout, your weight should be back up to normal.

    If you can’t check your weight, pay attention to your body for signs of
    dehydration. Your mouth should not be dry. Your urine should be
    lemon-colored most of the time.

    More than one episode of dark yellow urine is a warning sign that you don’t
    have much reserve. (Exception: Vitamin supplements can turn your urine
    yellow-orange, even if you are hydrated.) Loss of appetite, stomach aches,
    and muscle cramps can be other warning signals of dehydration.

  3. Nick Daverese, June 7, 2017 at 3:35 p.m.

    Part 3
    Drink before, during and after working out. Drink a pint or so of fluid a
    few hours before exercise. This will help make sure you are hydrated and
    give you enough time to urinate if you need to beforehand.

    Keep drinking during exercise. And don’t worry about getting too much fluid.
    If you’re sweating, your body needs a constant supply. Your stomach might
    gurgle, but your body will absorb and use the fluid. Feeling sick and
    cramping have been blamed on too much water when in fact, stomachaches and
    muscle cramps are usually signs of not drinking enough fluid.

    Drinking fluids after workouts is extremely important. Even when drinking
    fluids during a workout, many athletes become dehydrated. Athletes working
    out in the heat for several hours can lose 10 pounds. That’s more than a
    gallon of water.

    Hydration Tip: Keep your hydration source full and in plain sight so you
    remember to drink it.

  4. Nick Daverese, June 7, 2017 at 3:36 p.m.

    Part 4
    What Should I Drink?
    Your body needs water. But remember water comes in all sizes, shapes and
    colors. Milk is 90% water. Juice and most soft drinks are 89% water, sport
    drinks are 94% water, and even pizza is 50% water. And it all counts. Nearly
    everything that passes your lips provides water for your body, and in fact,
    research shows that most hydration happens at meals from the combination of
    food and beverages.

    Research also shows that we tend to drink more if the fluid is flavored and
    if a variety of fluids are available. Gatorade and water are two excellent
    sources for hydration.

    Keys to Hydration
    When you have figured out how to stay hydrated, especially when you sweat
    heavily, you have accomplished the single most important
    performance-enhancing aspect of nutrition.

    Water is your most important nutrient.

  5. Nick Daverese, June 7, 2017 at 3:37 p.m.

    Part 5
    Outline for Heat Illnesses
    Source: USOC Sports Medicine Division

    Heat illnesses are common problems for both athletes and non-athletes in
    hot, humid weather. Heat Cramps, Heat Exhaustion, and Heat Stroke start from
    similar circumstances: poor adjustment to hot weather and relative
    dehydration. These conditions can be severe and need emergency medical
    attention. All are preventable if certain procedures, such as time to adjust
    to heat, adequate fluids, and normal dietary electrolyte intake, are followed.

    Heat Cramps

    Inadequate adjustment to hot weather, heavy sweating; decreased blood levels
    of electrolytes; fluids and electrolytes not adequately replaced; unreplaced
    weight loss from previous workout/day.

    Clinical signs and symptoms
    Muscles in arms, legs, and/or abdomen spasm uncontrollably, accompanied by
    heavy sweating.

  6. Nick Daverese, June 7, 2017 at 3:38 p.m.

    Part 6
    Drink fluids; gently stretch and massage cramped muscles; rest in cool
    environment; apply ice to cramped area; watch for breathing or heart problems.

    Maintain adequate fluid intake by replacing sweat losses: 15-30 minutes
    before exercise, drink 16 oz. of fluid; during exercise, drink 8oz. every 15
    minutes; and after exercise drink 16 oz. of water/electrolyte drink (i.e.,
    PowerAde, Gatorade) for every pound of body weight loss; increase fitness;
    wear light colored and/or lightweight (i.e. mesh) clothing; do not use
    alcohol, coffee, caffienated drinks, or soda pop for fluid replacement.

  7. Nick Daverese, June 7, 2017 at 3:39 p.m.

    Part 7

    Heat Exhaustion

    Long exposure to hot and/or humid environment; heavy sweating; fluids and
    electrolytes not replaced adequately; unreplaced weight loss from previous

    Clinical signs and symptoms
    Skin cool, pale and moist; heavy sweating; headache; dizziness; poor
    coordination; mental dullness; enlarged pupils; nausea; vomiting; fatigue;
    weakness; thirsty; small urine volume (bright yellow color); possibility of

    Stop activity; rest in a cool area; sponge with cool water; drink water if
    conscious (replace weight loss with 16 oz of fluid for each pound of body
    weight); watch for breathing or heart problems; refer to physician attention
    if recovery does not occur quickly.

    Maintain adequate fluid intake by replacing sweat losses; 15-30 minutes
    before exercise drink 16 ounces of fluid, during exercise drink 8 ounces
    every 15 minutes, and after exercise drink 16 ounces of water-electrolyte
    drink (i.e. Powerade, Gatorade for every pound of body weight lost; increase
    fitness; wear light colored and/or lightweight (i.e. mesh) clothing; do not
    use alcohol, coffee, caffeinated drinks, or soda pop for fluid replacement;
    allow time for rest and cool down.

  8. Nick Daverese, June 7, 2017 at 3:41 p.m.

    Part 8 almost done :)

    Body’s temperature control system stops working.

    Clinical signs and symptoms
    Hot, dry and red skin; no sweating; rapid pulse; confusion; dizziness;
    unconsciousness; rectal temperature as high as 104°-106° Fahrenheit.

    Treatment: Medical Emergency!
    Immediate emergency cooling (e.g. cool room, put body in tub of ice water,
    ice cloths with a fan blowing on skin) and transport immediately to
    hospital; check temperature; watch for breathing or heart problems (may need

    Maintain adequate fluid intake by replacing sweat losses; 15-30 minutes
    before exercise drink 16 ounces of fluid, during exercise drink 8 ounces
    every 15 minutes, and after exercise drink 16 ounces of water/electrolyte
    drink (i.e. mesh) clothing; do not use alcohol, coffee, caffeinated drinks,
    or soda pop for fluid replacement; allow time for rest and cool down.

  9. Nick Daverese, June 7, 2017 at 3:43 p.m.

    Part 9 the end

    USOC Medical Emergency Procedures
    Heat Illness Guidelines

    Heat Cramps
    Musculature spasm of extremity and abdomen
    Heavy sweating
    Core temperature normal or slightly elevated

    Heat Exhaustion
    Cool, moist, pale or flushed skin
    Headache and dizziness
    Strong, slow pulse
    Weakness, confusion, and fatigue
    Nausea, vomiting

    Heat Stroke
    Usually, hot, dry, flushed skin
    Headache and dizziness
    Strong, slow pulse
    Heavy sweating, thirst
    Fluid and electrolyte depletion
    Enlarged pupils
    Possible unconsciousness

    Heat Cramps
    Cease activity and remove from heat
    Rest and drink cool fluids
    Monitor for change in symptoms

    Heat Exhaustion
    Cease activity and remove from heat
    Sponge with cool water
    Slowly administer cool fluids orally if conscious
    Monitor for change in symptoms

    Heat Stroke
    Activate EMS
    Remove wet clothing and sponge with cold water
    Monitor symptoms
    Remove from heat

    Heat Cramp/Heat Exhaustion
    Contact consulting physician if complications occur or symptoms do not resolve

    Heat Stroke
    Activate EMS

    Follow Up
    Heat Cramp/Heat Exhaustion
    Maintain adequate fluid intake, adequate rest and cooling periods,
    acclimatize to environment, physician release if indicated

    Heat Stroke
    Physician release to activity
    Maintain adequate fluid intake
    Adequate rest and cooling periods
    Acclimatize to environment

    Notify Head ATC or designee and appraise of situation

    Notify the emergency contact of the patient if they are a minor

  10. Fire Paul Gardner Now, June 8, 2017 at 9:44 a.m.

    Can't you just post a link?

  11. Nick Daverese, June 8, 2017 at 1:53 p.m.

    I did not get a link. He sent it to me on an email. I saved it. The problem is a save things I like even if it is long. Take what you like discard what you don't like.

    On hydration on hot days. Drink like crazy 3 days before a game in heat. In between games in tournament play find or make a place for them in the shade. Kid gets injured on a field. Have a medical kit that holds 6 bottles of water so everyone can get a drink. Give a bottle to keep in the back of the net. Heat stroke is serious it can kill you. Got to get used to playing in heat.

  12. Nick Daverese, June 8, 2017 at 1:55 p.m.

    Should see what we did playing in cold. Adults we put Ben Gaye on their legs :)

  13. Bob Ashpole, June 9, 2017 at 2:21 a.m.

    Important topic. Thanks Dr. Mishra.

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