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CLINICAL REPORT Guidance for the Clinician in Rendering Pediatric Care The Female Athlete Triad Amanda K. Weiss Kelly, MD, FAAP, Suzanne Hecht, MD, FACSM, COUNCIL ON SPORTS MEDICINE AND FITNESS The number of girls participating in sports has increased significantly since abstract the introduction of Title XI in 1972. As a result, more girls have been able to experience the social, educational, and health-related benefits of sports participation. However, there are risks associated with sports participation, including the female athlete triad. The triad was originally recognized as the interrelationship of amenorrhea, osteoporosis, and disordered eating, but our understanding has evolved to recognize that each of the components of the triad exists on a spectrum from optimal health to disease. The triad occurs when energy intake does not adequately compensate for exercise- This document is copyrighted and is property of the American related energy expenditure, leading to adverse effects on reproductive, Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy bone, and cardiovascular health. Athletes can present with a single of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of component or any combination of the components. The triad can have Pediatrics has neither solicited nor accepted any commercial a more significant effect on the health of adolescent athletes than on involvement in the development of the content of this publication. adults because adolescence is a critical time for bone mass accumulation. Clinical reports from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external This report outlines the current state of knowledge on the epidemiology, reviewers. However, clinical reports from the American Academy of diagnosis, and treatment of the triad conditions. 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. INTRODUCTION 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. The benefits of exercise in adolescents are well established, including DOI: 10.1542/peds.2016-0922 improved self-esteem, fewer risk-taking behaviors, increased bone mineral density (BMD), and decreased obesity.1–3 However, when PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). exercise occurs without adequate energy intake to compensate for Copyright © 2016 by the American Academy of Pediatrics exercise-related energy expenditure, there may be adverse effects on FINANCIAL DISCLOSURE: The authors have indicated they reproductive, bone, and cardiovascular health. The female athlete triad have no financial relationships relevant to this article to (referred to hereafter as the “triad”) was first widely acknowledged disclose. as the 3 interrelated conditions of amenorrhea, osteoporosis, and FUNDING: No external funding. disordered eating in an American College of Sports Medicine position statement published in 1997.4 Since that time, a more inclusive definition POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to has evolved because it has become clear that each component of the disclose. triad exists on a spectrum; the 3 components were renamed menstrual function, BMD, and energy availability (EA) to more accurately represent the spectrum, which can range from optimal health to disease in each To cite: Weiss Kelly AK, Hecht S, AAP COUNCIL ON SPORTS MEDICINE AND FITNESS. The Female Athlete Triad. Pediatrics. component.5 In addition, athletes may present with 1, 2, or all 3 of the 2016;137(6):e20160922 components. Downloaded from www.aappublications.org/news by guest on March 17, 2020 PEDIATRICS Volume 138, number 2, August 2016:e20160922 FROM THE AMERICAN ACADEMY OF PEDIATRICS
Adolescent athletes are in a critical age at sport specialization, family TABLE 1 Examples of Sports Emphasizing period of bone mass accumulation, dysfunction, abuse, and dieting.5,17 Leanness and Endurance so the triad disorders can be Wrestling particularly harmful in this group.6 Energy Availability Light-weight rowing Appropriate intervention during the Gymnastics EA is defined as daily dietary energy Dance adolescent years may improve peak intake minus daily exercise energy Figure skating bone mass accrual, an important expenditure corrected for fat-free Cheerleading predictor of postmenopausal mass (FFM).5 Optimal EA has been Long and middle distance running osteoporosis, potentially preventing Pole vaulting identified to be 45 kcal/kg FFM per low BMD, postmenopausal day in female adults but may be osteoporosis, and fractures in even higher in adolescents who are is also a strong predictor for low adulthood. Two investigators have still growing and developing. The BMD.13 Athletes with a high drive also identified lower BMD as a risk spectrum of EA ranges from optimal for thinness or increased dietary factor for stress fracture in athletes.7,8 EA to inadequate EA, with or without restraint (an intention to restrict It is difficult to estimate the true the presence of disordered eating/ food intake to control weight) are prevalence of the triad because of eating disorder. Recently, it has significantly more likely to have low the complexity of evaluation of each become clear that many athletes BMD or to sustain a musculoskeletal of the components. Reports have affected by the triad do not exhibit injury than are athletes with normal indicated that the prevalence of pathologic eating behaviors, and eating behaviors.26,27 individuals with all 3 components their low EA is unintentional. Low EA simultaneously is only 1% to 1.2% in Many triggers for the onset of adversely affects bone remodeling, high school girls9,10 and 0% to 16% disordered eating in athletes have and EA
triad can range from anovulation and TABLE 2 Causes of Secondary Amenorrhea in is likely attained between the ages luteal dysfunction to oligomenorrhea Adolescents of 20 and 30 years.42,43 By the end and amenorrhea (primary or Pregnancy of adolescence, almost 90% of adult secondary). Primary amenorrhea is Polycystic ovarian syndrome bone mass has been obtained.43 defined as the absence of menarche Pituitary tumor Prolactinoma Genetics, participation in weight- by the age of 15 years.29 The Hyperthyroidism bearing activities, and diet all absence of other signs of pubertal Liver/kidney disease influence bone mass in children.44 development by 14 years of age Medications: oral contraceptive pills, Appropriate dietary intake and or a failure to achieve menarche chemotherapy, antipsychotics, antidepressants, corticosteroids weight-bearing exercise can within 3 years of thelarche is positively influence maximum bone Eating disorders also abnormal.29,30 Secondary mass gains during childhood and amenorrhea is defined as the absence adolescence. With improved EA of menses for 3 consecutive months oligomenorrhea ranges from 5.4% and resumption of menses, some or longer in a female after menarche. to 18%.10,15,21,22,24,31 The prevalence “catch up” bone mass accrual may be Oligomenorrhea is defined as of anovulation and luteal phase possible in athletes with the triad; menstrual cycles longer than 35 days. deficiency has not been evaluated in however, some will have persistently Luteal phase deficiency is defined as adolescent athletes but ranges from lower BMD than their genetic a menstrual cycle with a luteal phase 5.9% to 30% in adult athletes.11 potential, highlighting the need for shorter than 11 days in length or with early, aggressive intervention in Amenorrheic adolescent athletes a low concentration of progesterone. adolescent athletes identified with have a significantly lower BMD than Menstrual disturbances, such triad components.45 eumenorrheic adolescent athletes as anovulation and luteal phase or sedentary controls.13,31,33 Some BMD in children and adolescents is deficiency, are asymptomatic, making studies have found that athletes typically evaluated by using dual- them difficult to diagnose by history with menstrual irregularities are energy radiograph absorptiometry alone. After excluding other causes of as much as 3 times more likely to (DXA), which is best performed amenorrhea (Table 2), amenorrhea sustain bone stress injury and other and interpreted by centers with in the setting of inadequate EA is musculoskeletal injury than are certified clinical densitometrists with diagnosed as functional hypothalamic eumenorrheic athletes,26,34–36 but knowledge of the official pediatric amenorrhea.5 The word “functional” this finding has not been consistent.37 positions of the International Society indicates suppression, attributable to Oligomenorrhea and amenorrhea for Clinical Densitometry.6,46,47 lack of energy, of an otherwise intact have also been associated with Because athletes participating in reproductive endocrine axis. cardiovascular risk factors, including weight-bearing sports are expected to increased cholesterol and abnormal have higher BMDs than nonathletes, Menstrual irregularities are endothelial function.38,39 In the American College of Sports common during adolescence and addition, menstrual disturbance has Medicine recommends different are significantly more common in recently been related to decreased criteria than the International Society adolescent athletes. Of the published performance in swimmers with for Clinical Densitometry, as shown studies of menstrual disturbances evidence of ovarian suppression in Table 3. In athletes, a Z-score in adolescent athletes, only 1 study compared with those without ovarian below –1.0 is considered lower than included a sedentary control group. suppression.40 expected and indicates that, even That study reported an incidence of menstrual irregularity of 21% in in the absence of previous fracture, Bone Health secondary causes of low BMD may sedentary adolescents compared with 54% in adolescent athletes.9 The decreased rate of bone be present.5 A full discussion of the Other studies reported menstrual acquisition that can be associated secondary causes of low BMD is disturbances in adolescent athletes with the triad in adolescent athletes beyond the scope of this report, but ranging from 12% to 54% for any is particularly concerning, because evaluations for secondary causes menstrual irregularity (primary bone mass gains during childhood typically include the items in Table 4.48 or secondary amenorrhea or and adolescence are critical for Measures of bone microarchitecture, oligomenorrhea).9–11,21,22,24,31,32 the attainment of maximal peak although primarily used for research When evaluating specific types of bone mass and the prevention of purposes at this juncture, can add menstrual irregularity, primary osteoporosis in adulthood.6,41 The additional information regarding amenorrhea in athletes ranges from maximum rate of bone formation bone quality beyond that of 1.2% to 6%, secondary amenorrhea usually occurs between the ages of BMD. Favorable changes in bone ranges from 5.3% to 30%, and 10 and 14 years, and peak bone mass microarchitecture are associated Downloaded from www.aappublications.org/news by guest on March 17, 2020 PEDIATRICS Volume 138, number 2, August 2016 e3
TABLE 3 Definition of BMD Criteria in Adolescents ISCD Official Position for Children and Adolescents46 ACSM Guidelines for Athletes5 Osteoporosis Vertebral compression fracture or Z-score ≤ –2 and Z-Score ≤2 and clinical risk factorsb clinically significant fracture historya Low BMD — Z-Score –1.0 to –1.9 and clinical risk factors Lower BMD than expected — Z-Score ≤ –1.0 ACSM, American College of Sports Medicine; ISCD, International Society for Clinical Densitometry. a Two or more long bone fractures by age 10 or ≥3 long bone fractures at any age up to 19 years. b Nutritional deficiencies, hypoestrogenism, or stress fracture. with sports participation in female TABLE 4 Evaluation for Low BMD (BMD < –1.0) adolescents. Weight-bearing athletic • Serum 25-hydroxyvitamin D activity is associated with greater • Serum calcium total trabecular area and greater • Complete blood count with differential cortical perimeter in the tibia.49 • Thyroid-stimulating hormone • Parathyroid hormone Conversely, oligomenorrhea and • Bone-specific alkaline phosphatase amenorrhea are associated with • 24-h urine for calcium unfavorable bone microarchitecture, • Screening for cortisol excess: morning cortisol or 24-h urine for cortisol including lower total density, lower • Celiac disease: serum tissue transglutaminase antibodies, total IgA, tissue transglutaminase IgG (in the trabecular number, and greater IgA-deficient adolescent) • Markers of bone formation and resorption: serum osteocalcin and urine N-telopeptide trabecular separation at the tibia.49 • Reproductive hormone evaluation: estradiol, FSH, LH in girls, testosterone in boys Estimations of bone strength FSH, follicle-stimulating hormone; IgA, immunoglobulin A; IgG, immunoglobulin G; LH, luteinizing hormone. indicate that eumenorrheic, but not amenorrheic, athletes have greater stiffness and load-to-failure runners have lower BMDs than restraint, greater length of time thresholds, which are associated with sprinters, gymnasts, and ball sport participating in endurance sports, decreased fracture risk, compared athletes.31,51–56 Barrack et al53 lower body weight, and lower with nonathlete controls.11,50 reported a higher prevalence of BMI.1,13,31,32,52 The deficits in low BMD in adolescent endurance BMD seen with the triad are Although it is well known that runners (40%) than in ball or power associated with low estrogen levels exercise is a stimulus for bone sport athletes (10%). This study and energy deficiency. Levels of formation, data support that different also showed that runners 17 to 18 bone formation and resorption types of exercise can have differing years of age had similar bone mineral markers are significantly lower in effects on bone formation. For content (BMC) compared with 13- to amenorrheic adolescent athletes than example, adolescent and collegiate 14-year-old runners, whereas BMC in nonendurance athlete controls, swimmers have been shown to in nonrunner athletes showed a indicating a state of overall decreased have a similar BMD compared significantly higher BMC in the older bone turnover.33 The restriction of with nonathlete controls and to group compared with the younger EA has been shown to cause estradiol have a lower BMD compared with group. These findings suggest suppression and increased bone athletes in other sports.48 In fact, a a possible suppression of bone resorption as well as suppression of longitudinal BMD study in swimmers, accumulation in adolescent runners, bone formation.19 gymnasts, and nonathlete controls although other factors may be A recent multisite prospective over an 8-month competitive contributing to this finding, including study34 identified the contribution season showed that swimmers and possible variable bone accrual of single and multiple triad-related controls had no improvement in patterns attributable to genetics, rate risk factors for bone stress injury in BMD, whereas gymnasts showed of maturation, specific type of current 259 female adolescents and young significant BMD gains despite more and previous physical activity, and adults participating in competitive body dissatisfaction and menstrual EA and menstrual differences often or recreational exercise. The authors disturbance.51 found between endurance runners found an increased risk of bone and nonendurance athletes.53 stress injuries as the number of triad- Numerous studies have shown running to have a positive effect Many factors are associated with related risk factors increased.34 on BMD compared with inactive an increased risk of low BMD in controls,48 but there is emerging female adolescent athletes, including Cardiovascular Health concern, predominantly from cross- late menarche, oligomenorrhea, Endothelial dysfunction, measured sectional studies, that endurance amenorrhea, elevated dietary by brachial artery flow-mediated Downloaded from www.aappublications.org/news by guest on March 17, 2020 e4 FROM THE AMERICAN ACADEMY OF PEDIATRICS
dilation (FMD), is an important TABLE 5 The Female Athlete Triad Coalition’s Recommended Screening Questions for the Female predictor of coronary endothelial Athlete Triad68 dysfunction, atherosclerotic disease Question Included on the Fourth- progression, and cardiovascular Edition PPE Form69 event rates.38,57,58 Endothelial 1. Do you worry about your weight or body composition? √ dysfunction has been correlated 2. Do you limit or carefully control the foods that you eat? √ with low whole-body and lumbar 3. Do you try to lose weight to meet weight or image/appearance √ requirements in your sport? BMD, menstrual dysfunction, and 4. Does your weight affect the way you feel about yourself? — low estrogen levels in dancers and 5. Do you worry that you have lost control over how much you eat? — endurance athletes.38,39 In endurance 6. Do you make yourself vomit or use diuretics or laxatives after you eat? — athletes, oligomenorrheic and 7. Do you currently or have you ever suffered from an eating disorder? √ amenorrheic athletes had impaired 8. Do you ever eat in secret? 9. What age was your first menstrual period? √ FMD compared with eumenorrheic 10. Do you have monthly menstrual cycles? √ athletes, with amenorrheic athletes 11. How many menstrual cycles have you had in the last year? √ showing the greatest impairment.39 12. Have you ever had a stress fracture? √ In this group, amenorrhea was also associated with increased menstrual cycles, but they may Female Athlete Triad Coalition and total cholesterol and low-density show suppression of reproductive has been endorsed by the American lipoprotein levels.39 Among function nonetheless. There is a Academy of Pediatrics (AAP) for use professional dancers, endothelial small body of data suggesting that when performing the PPE (Table 5). dysfunction alone was present in male athletes with inadequate EA If an athlete answers “yes” to any of 64%, whereas the prevalence of may also suffer from hormonal the triad questions on the PPE form, dancers with endothelial dysfunction changes and low BMD. Lower the remaining questions from the and all 3 components of the triad testosterone levels have been found Female Athlete Triad Coalition68 can was 14%.38 All of the dancers in male runners compared with be used for further evaluation. who reported current menstrual inactive controls.61 Similar to female A sports level of participation dysfunction (36%) had reduced athletes, male endurance runners and return-to-play medical risk FMD.38 Amenorrheic runners and have been found to have lower stratification scoring rubric has dancers treated with 4 weeks of BMD than male athletes in power or been developed by the Female folic acid supplementation showed ball sports.62 Adolescent males with Athlete Triad Coalition Consensus improvements in FMD.15,59 Although anorexia nervosa display low BMD at Panel to help the clinician assess these studies were not exclusive multiple skeletal sites.60,63 an athlete with triad-related risk to adolescents, adolescents were Although the body of scientific factors into low-, moderate-, or included in the study populations. evidence is still developing, it is high-risk categories. Decisions These results raise concern that important to consider that adolescent regarding sports participation, level an athlete diagnosed with the males participating in sports that of participation permitted, and triad could be at risk of developing emphasize and reward leanness return-to-play are made on the basis cardiovascular disease. may be at risk of a constellation of of the risk category that the athlete findings similar to those seen in falls into and can be reassessed females with components of the as the athlete progresses through MALE ATHLETES triad.64–66 treatment.68 Although female athletes have been the exclusive focus of research on SCREENING DIAGNOSIS the triad, low EA resulting in the suppression of the neuroendocrine It is convenient to screen for the Obtaining a complete nutritional, reproductive axis is likely not triad at the time of a well-child visit menstrual, fracture, and exercise gender selective. Low testosterone and/or the preparticipation physical history is the first step in diagnosis. and estradiol levels have been evaluation (PPE). The Female Athlete Vital signs may reveal bradycardia, documented in adolescent males Triad Coalition has developed 12 which can also be a normal finding diagnosed with anorexia nervosa.60 questions for screening (Table 5).67–69 in well-trained athletes; orthostatic This finding begs the question: is Another screening tool is found in hypotension; low body weight (
eating disorders, cold/discolored TABLE 6 Factors Prompting BMD Evaluation in Athletes With Stress Fracture hands and feet, hypercarotenemia, Low BMI (30 they may give the athlete a false disorder, a chemistry profile and kcal/kg FFM per day can restore sense of security that EA has been electrocardiography can be used to menses, although an EA >45 kcal/ restored, so their use is typically evaluate for possible arrhythmia or kg FFM per day is optimal.5,71 FFM avoided unless they are being metabolic disturbance. BMD testing can be measured by using DXA, prescribed for other indications. It by DXA is indicated in athletes with air-displacement plethysmography is important to recognize that the any of the following: eating disorder (ie, BodPod analysis [National hormonal environment provided (diagnosed by using criteria of the Institute for Fitness and Sport, by oral contraceptive pills is not Diagnostic and Statistical Manual of Indianapolis, IN]), bioelectrical the same as a naturally occurring Mental Disorders, Fifth Edition70), impedance analysis, or skinfold menstrual cycle. Misra et al75 weight 85% expected weight, and a treatment.5,6 Significantly more Improving EA is the cornerstone of minimum daily energy intake of 2000 athletes with stress fractures have treatment of the triad disorders and kcal.48,60 A gradual increase of 200 low calcium intakes than do athletes has been associated with the return to 600 kcal/day and a reduction in without stress fractures.35 Assessing of normal menses and improvements training volume of 1 day per week 25-hydroxyvitamin D concentration in BMD.5,48,60 A multidisciplinary are usually sufficient to attain the is useful in athletes presenting team approach is suggested and may needed improvements in weight and with components of the triad.1,46 include a physician, a dietitian, a EA.48,71 It is important to recognize The AAP currently recommends a certified athletic trainer, a behavioral that the resumption of menses may daily intake of 1300 mg calcium for health clinician, and, at times, an take up to 1 year or longer after children and adolescents ages 9 to exercise physiologist. It is preferable restoration of appropriate EA.48 A 18 years and 600 IU vitamin D for that the medical team be familiar written treatment plan (contract) children and adolescents ages 1 to with treating athletes. For athletes signed by the providers and athlete/ 18 years, although many experts with an unintentionally low EA parent(s) can be a useful tool to recommend higher intakes of without features of disordered eating outline and define the treatment vitamin D, particularly in climates or an eating disorder, a behavioral plan and expectations on the part of where sun exposure is limited.1 health clinician may not be needed. the athlete, parent(s), and medical The International Osteoporosis Improvements in EA can be providers (for a sample contract, see Foundation calcium calculator can accomplished by both decreasing the Supplementary Data in ref 48). be used as a tool to estimate calcium Downloaded from www.aappublications.org/news by guest on March 17, 2020 e6 FROM THE AMERICAN ACADEMY OF PEDIATRICS
intake from dietary sources (www. unhealthy behaviors. Refusal skills normal in athletes and may be iof.org). In addition to calcium were practiced, and healthy norms detrimental to their health and and vitamin D, other vitamins and were reinforced. The control schools performance. minerals are known to play a role received pamphlets regarding 4. Functional hypothalamic in bone health (B vitamins, vitamin disordered eating, drug use, and amenorrhea is a diagnosis of K, and iron), thus underscoring the sports nutrition. Questionnaires exclusion made after other importance of a well-balanced diet. administered before and after the causes for primary and program revealed decreased use of Bisphosphonates are antiresorptive secondary amenorrhea have diet pills, decreased intent to vomit agents frequently used in the been evaluated. The restoration to lose weight, and improved healthy treatment of postmenopausal of optimal EA is the cornerstone eating behaviors in the teenagers osteoporosis. Unlike postmenopausal of treatment of functional in intervention schools. This trial osteoporosis, the mechanism of low hypothalamic amenorrhea. shows that primary intervention BMD in athletes affected by the triad 5. The resumption of menses may techniques that use education with is predominantly attributable to take up to 1 year or longer after peer leaders can reduce the risk of decreased bone formation rather than restoration of appropriate EA. disordered eating and other risk- increased bone resorption. Therefore, taking behaviors. 6. Oral contraceptive pills are bisphosphonates would likely be less effective in athletes with the triad.20 not the first-line intervention Other concerns regarding treatment for an athlete with functional CONCLUSIONS AND GUIDANCE FOR THE with bisphosphonates include their CLINICIAN hypothalamic amenorrhea. long half-life and potential teratogenic 7. Weight-bearing exercise in effects, thus making it prudent to 1. The well-child visit or PPE provides an opportune time for the context of appropriate avoid them in females of childbearing nutritional intake is important age.6 It is important to note that the the pediatrician to screen for and provide education and guidance for the enhancement of bone US Food and Drug Administration mass accrual. has not approved any pharmacologic regarding the components of the interventions for the treatment of female athlete triad and the risks 8. The criteria for performing DXA to osteoporosis in premenopausal of inadequate EA for athletes. The measure BMD in athletes include females. AAP has published a PPE form menstrual dysfunction or low EA that includes a comprehensive (45 kcal/kg FFM per weight-control behaviors, drug use, inadequate energy intake. day. FFM can be determined by and risk-taking behaviors.77 This Patients presenting with using DXA, biometrical impedance randomized controlled intervention menstrual dysfunction measurements, or skinfold included eight 45-minute, small- provide an opportunity for the measurements. group classroom sessions guided pediatrician to counsel parents 10. When treating athletes with by peer leaders. The curriculum and adolescent athletes that the triad, a multidisciplinary included education regarding menstrual dysfunction and team capable of addressing substance use, nutrition, and restricted energy intake are not the medical, nutritional, Downloaded from www.aappublications.org/news by guest on March 17, 2020 PEDIATRICS Volume 138, number 2, August 2016 e7
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The Female Athlete Triad Amanda K. Weiss Kelly, Suzanne Hecht and COUNCIL ON SPORTS MEDICINE AND FITNESS Pediatrics 2016;138; DOI: 10.1542/peds.2016-0922 originally published online July 18, 2016; Updated Information & including high resolution figures, can be found at: Services http://pediatrics.aappublications.org/content/138/2/e20160922 References This article cites 73 articles, 9 of which you can access for free at: http://pediatrics.aappublications.org/content/138/2/e20160922#BIBL Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Current Policy http://www.aappublications.org/cgi/collection/current_policy Council on Sports Medicine and Fitness http://www.aappublications.org/cgi/collection/council_on_sports_me dicine_and_fitness Sports Medicine/Physical Fitness http://www.aappublications.org/cgi/collection/sports_medicine:physi cal_fitness_sub Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.aappublications.org/site/misc/Permissions.xhtml Reprints Information about ordering reprints can be found online: http://www.aappublications.org/site/misc/reprints.xhtml Downloaded from www.aappublications.org/news by guest on March 17, 2020
The Female Athlete Triad Amanda K. Weiss Kelly, Suzanne Hecht and COUNCIL ON SPORTS MEDICINE AND FITNESS Pediatrics 2016;138; DOI: 10.1542/peds.2016-0922 originally published online July 18, 2016; The online version of this article, along with updated information and services, is located on the World Wide Web at: http://pediatrics.aappublications.org/content/138/2/e20160922 Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. Pediatrics is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2016 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397. Downloaded from www.aappublications.org/news by guest on March 17, 2020
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