Ballet and Dance

Dance is an artistic, athletic, expressive, and social form of physical activity that appeals to a wide variety of individuals. The physical aspects of dance can be both a valuable source of exercise as well as a cause of injury. For young people who take dance classes, have formal training in dance, or perform as dancers, they typically do so in one of the following dance disciplines: ballet, jazz, modern, tap, hip hop, Irish, or lyrical.
There are many forms of dance that have unique physical demands and specific injury risks. There are also some physical demands that are common to a wide variety of dance forms. For example, many types of dance involve jumping, turning, toe pointing, back arching, and lifting. These activities can produce tendinosis, stress fractures, ankle sprains, ankle impingement, or low back pain.
The following is information from the American Academy of Pediatrics about common ballet and dance injuries and their symptoms. Also included are 3 common questions from dancers.

Common injuries

Injury	Description/Cause	Symptoms
Flexor hallucis longus tendonitis	Inflammation of tendon that flexes big toe; tendon is stressed with releve, jumps, pointe work.	Pain, tightness, and/or weakness along the tendon in arch or behind the inner part of the ankle.
Symptomatic os trigonum	Extra piece of bone behind ankle joint (found normally in 20% of individuals) gets pinched when the toes are pointed and ankle is flexed downward.	Pain, tightness, and occasional swelling behind ankle associated with releve, pointe work, and going up on toes.
Anterior talar impingement	Pinching of soft tissues in front of ankle with ankle bending upward.	Pain, tightness, pinching sensation in front of ankle with plié, preparing to jump, and landing from jump.
Ankle sprain	The ankle inverts (collapses inward) most commonly when dancers are on their toes while jumping, landing, or turning.	Pain, swelling on outer ankle; sense of instability with sideways movement; sprains are more common if there has been a previous sprain.
Stress fracture	Repetitive impact stress can cause weakening of bone; often without a visible crack seen on x-ray. Common in metatarsals (forefoot), tarsals (midfoot), tibia, and fibula (leg) and occasionally femur, pelvis, and spine.	Persistent, deep, bony pain associated with high levels of impact activity; more common in dancers with calcium or vitamin D deficiency, eating disorders, and menstrual irregularities.
Patellofemoral pain syndrome	Pain under the kneecap from pressure associated with knee bending, pliés, jumps; can lead to softening or thinning of cartilage behind the kneecap.	Dull, achy anterior knee pain that increases with knee bending, pliés, and jumps.
Snapping hip	Multiple causes including tendon snapping over front or side of hip; associated with active hip movement; occasionally due to torn cartilage lining the hip socket but very unlikely due to dislocating hip.	Snapping sensation that may or may not be painful; occasionally, dancer has a sense that the hip is going out of place; occasionally, there is a catch or pinching sensation deep in joint when hip is bending.
Pars injury	The pars interarticularis is a part of the spine that is stressed with back extension (arching); pain or weakening of the pars most commonly occurs during periods of rapid bony growth. Injuries to this area may be referred to as spondylolysis, or stress fracture of the spine.	Tightness, achiness in central part of the low back that is worse with arching, jumping, running, and lying prone; better with forward bending; nerve symptoms and radiating pain are rare with this condition.
Disc injury	Weakening or bulging of lumbar disc; due to repetitive trunk bending, twisting, or lifting. Athletes may also get a vertebral end plate (growth plate) injury.	Low back pain that extends to the flank or buttock; may spread to thigh; occasional numbness or tingling; worse with sitting, bending, lifting, and lying down with face up; better with arching and lying down with face down.

Frequently asked questions

Q: When can I begin pointe work?

A: En pointe refers to performing dance steps on the tips of the toes. This technique is used only by female dancers. Trying pointe work too soon can lead to risk of sprains, fractures, and growth plate injuries. Most experts believe that a dancer is ready to try pointe work when the following criteria are met:

• Age range 9 to 15 years; 12 is average (assuming other criteria below are met)
• Three or more years of classical ballet training; 2 or more classes/week of preprofessional training (Instructors who have trained professional dancers can usually determine when a dancer has the necessary experience, technical skill, and strength to go en pointe.)
• Sufficient bony maturation
• Adequate strength in arch, ankle, leg, hips, trunk muscles
• Adequate balance and control
• Adequate supervision and training, including carefully graded skill progressions and monitoring

Q: Can I improve my turnout?

A: Turnout refers to the ability to externally rotate the hip. Not all dancers can achieve optimal turnout because they may be limited by their bony anatomy. For example, the depth and angle of a dancer’s hip socket may affect how far he or she can rotate his or her hip. However, most dancers can improve their turnout with appropriate exercises. For example, turnout can be improved by stretching the hip joint and the muscles on the inner side of the hip joint.
Optimal turnout allows dancers to stand with their feet pointing opposite directions while their knees are positioned directly over the feet. If turnout is not done correctly, dancers are either unable to hold this position or they “cheat” by twisting their knees or forcing their lower legs to the outside. When the hip, knee, and foot are not in alignment, leg and low-back injuries can occur.

Q: How can I safely lose weight?

A: Dancers of all ages face tremendous pressure to be thin. The pressure may be based on aesthetic or performance requirements. At times, targeted weight goals may be unhealthy. Not getting enough calories and nutrients can contribute to less energy, impaired brain functioning (like poor concentration), and increased risk of illness and injury. When unsafe weight loss practices are used to reach a desired appearance, health risks can include serious illness, hospitalization, and even death.
Dancers who want to lose weight should use a medically supervised strategy. This includes working with a medical professional to determine how much weight loss is safe, how quickly the weight can be lost and how nutritional and energy requirements will be met. It may also be helpful to work with a registered dietitian. It is essential to have regular medical monitoring to evaluate the safety and efficacy of the weight loss program.
For answers to additional questions about injuries, injury prevention, and safe training practices, talk with your doctor or a physical therapist.

Overcoming Obstacles to Physical Activity

There are many benefits of regular physical activity; however, people often have many excuses for not being more physically active. The following is information from the American Academy of Pediatrics encouraging families to consider all the benefits of being physically active and how to overcome some obstacles. Each family member can take a step toward becoming more physically active by filling out the physical activity plan.

Benefits of being physically active

Being physically active is one way you can

• Have fun—this is important!
• Spend time with friends.
• Improve your body image.
• Maintain a healthy weight.
• Increase energy levels.
• Improve your self-image.
• Feel stronger.
• Increase your endurance for sport or hobbies.
• Get muscles or definition.
• Decrease stress.

Overcoming common obstacles

The following are suggestions on how to overcome 4 common barriers to physical activity.
1. “I don’t have time.”
What you can try

• Build activity into your day: walk or ride your bike for transportation.
• Get off the bus a stop early and walk the rest of the way.
• Take the stairs whenever possible.
• Plan fun, “active” activities with friends and family.
• Sign up for physical education at your school.
• Walk around the mall twice before you start shopping.

2. “I don’t like sports” or “I’m not good at any sports.”
What you can try

• Consider active hobbies, like gardening. You don’t have to play a sport to be active.
• Choose an activity that you enjoy. Dancing, bicycling, and swimming are fun choices. And walking counts too.
• Consider volunteer work, like helping at a youth center or serving meals at a shelter.
• Find a friend, sibling, or other family member to be an “activity buddy” and schedule a fun activity 2 to 3 times a week.

3. “My neighborhood isn’t safe.”
What you can try

• Use a workout video or DVD in your home.
• Dance in your home to your favorite music.
• Find a YMCA, Boys and Girls Club, or community recreation center in your neighborhood.
• Sign up for school activities such as physical education or after-school programs.

4. “I’m overweight or out of shape.”
What you can try

• Start slow with 10 to 15 minutes of activity; walking is a great start.
• Build short activity breaks into your day; take the stairs!
• Count up your daily sit-down activities (computer, video games, TV time) and decrease them by 30 minutes.
• Join an after-school program or community program that involves activity or learning a new skill—get a friend to go with you.

Physical Activity Plan

Each member can use the following questions to help create a personal physical activity plan. Parents can help their children answer the questions. Parents also should remember that they can be powerful role models and can shape their children’s perception of physical activity and exercise.

1. What are the main benefits I want from being physically active?
2. What are the reasons or barriers that keep me from being active?
3. If necessary, what will be my solutions to these barriers?
4. What activity or activities am I going to do?
5. Where am I going to do this activity?
6. When am I going to be active (include time of day and on which days of the week)?
7. How long or how many minutes will I be active each day?
8. Who will be my activity buddy? 

Core Exercises: Guidelines and Examples

Core exercises strengthen the muscles of the spine, abdomen, and pelvis. These muscles support all physical activity.

General guidelines

Core exercises should not be painful. When pain develops, exercises may need to be modified or exercises even may need to be stopped. In some cases, it may be necessary to obtain further professional consultation if symptoms persist.
When core exercises are being done to help with sports performance or injury prevention, it may be necessary to start with very simple exercises and progress to more challenging exercises only when proper exercise techniques have been established.
When core exercises are being done to treat a back injury, it is helpful to get specific recommendations from your doctor or physical therapist before proceeding.
Regular breathing patterns should be maintained during core strengthening exercises—even if many of the exercises require contracting and holding the muscles in one position. Breath-holding can increase blood pressure and decrease the intended strength gains in the muscles.
Core strength helps maintain the spine, hips, and pelvis in a neutral position—even when the arms or legs are moving. Again, a trained therapist can help provide feedback as to the adequacy of maintaining a neutral spine. It may also be possible for the athlete (patient) to sense abnormal movement by placing their hand on the back of the pelvis and sacrum during a stabilization exercise.
One of the most basic core exercises involves a low intensity contraction of the pelvic floor in what is known as a Kegel exercise. This involves tightening the same muscles used to stop the flow of urine. Contracting muscles that gently hollow or draw in the abdominal area below the belly button is also a prerequisite for the proper use of other muscles that help stabilize the spine.

Examples of core exercises

Bridge with knee extension

1. Lie on your back with both knees bent and feet flat on the floor. Place your right and left hands on the floor with arms extended and palms facing the floor.
2. Lift your buttocks 1 to 2 inches off the floor and hold this position.
3. Keep your pelvis level and still as you slowly straighten a knee. Only your knee should move. Your thighs should remain still.
4. Lower your leg to the starting position and then repeat on the other side. Perform 10 repetitions on each leg, alternating between left and right sides.

Superman

1. Lie face down on the floor with your arms extended forward.
2. Lift your left arm and right leg off the ground. Tighten your abdominal muscles before lifting arms and legs.
3. Hold for 1 to 3 seconds then relax.
4. Lift your right arm and left leg off the ground. Again tighten your abdominal muscles before initiating.
5. Hold for 1 to 3 seconds then relax.
6. Repeat. Perform 10 repetitions for steps 2 and 3, and 10 repetitions for steps 4 and 5.

Clam

1. Lie on your side in a semi-fetal position. Both hips and knees should be bent to about 45 degrees. Your back should be straight, and hips and shoulders should be at a right angle to the floor (straight up and down).
2. Place your top hand on your pelvis to make sure the pelvis does not move.
3. Keep your pelvis, low back, and shoulders still, and your heels together, as you slowly raise your top knee toward the ceiling. Only move as far as you are able without letting your pelvis, low back, or shoulders move, then return to the starting position.
4. Perform 10 repetitions on one leg, then 10 repetitions on the opposite leg.

Childhood Depression: What Parents Can Do To Help

What is childhood depression?

Depression may be present when your child has:

• A sad or irritable mood for most of the day. Your child may say they feel sad or angry or may look more tearful or cranky.
• Not enjoying things that used to make your child happy.
• A marked change in weight or eating, either up or down.
• Sle​eping too little at night or too much during the day.
• No longer wanting to be with family or friends.
• A lack of energy or feeling unable to do simple tasks.
• Feelings of worthlessness or guilt. Low self-esteem.
• Trouble with focusing or making choices. School grades may drop.
• Not caring about what happens in the future.
• Aches and pains when nothing is really wrong.
• Frequent thoughts of death or suicide.

Any of these signs can occur in children who are not depressed, but when seen together, nearly every day, they are red flags for depression.

What should I do if I think my child is depressed?

• Talk to your child about his feelings and the things happening at home and at school that may be bothering him. 
• Tell your child's doctor. Some medical problems can cause depression. Your child's doctor may recommend psychotherapy (counseling to help people with emotions and behavior) or medicine for depression.
• Your child's doctor may now screen your child for depression every year from ages 11 through 21, with suicide now a leading cause of death among adolescents. Treat any thoughts of suicide as an emergency. 

What can I do to help?

Promote health

• The basics for good mental health include a healthy diet, enough sleep, exercise, and positive connections with other people at home and at school.  
• Limit screen time and encourage physical activity to help develop positive connections with others.
• One-on-one time with parents, praise for good behavior, and pointing out strengths build the parent-child bond. 

Provide safety and security

• Talk with your child about bullying. Being the victim of bullying is a major cause of mental health problems in children.
• Look for grief or loss issues. Seek help if problems with grief do not get better. If you as a parent are grieving a loss, get help and find additional support for your child.
• Reduce stress. Short-term changes in the amount of schoolwork, chores, or activities, may be needed.
• Weapons, medicines (including those you buy without a prescription), and alcohol should be locked up.

Educate others

• Your child is not making the symptoms up.
• What looks like laziness or crankiness can be symptoms of depression.
• Talk about any family history of depression to increase understanding.

Help your child learn thinking and coping skills

• Help your child relax with physical and creative activities. Focus on the child's strengths.
• Talk to and listen to your child with love and support. Help your child learn to describe their feelings.
• Help your child look at problems in a different more positive way.
• Break down problems or tasks into smaller steps so your child can be successful.

Make a safety plan

• Follow your child's treatment plan. Make sure your child attends therapy and takes any medicine as directed.
• Treatment works, but it may take a few weeks. The depressed child may not recognize changes in mood right away.
• Develop a list of people to call when feelings get worse.
• Watch for risk factors for suicide. These include talking about suicide in person or on the internet, giving away belongings, increased thoughts about death, and substance abuse.
• Locate telephone numbers for your child's doctor and therapist, and the local mental health crisis response team. 
• The National Suicide Prevention Lifeline can reached at 1 800-273-8255 or online at www.suicidepreventionlifeline.org.

Teens and Acne Treatment

I'm starting to get pimples! What can I do to get rid of them?

The bad news—There's no cure for acne. The good news—It usually clears up as you get older. In the meantime, there are a few things you can do to help keep those zits under control.

Types of treatments

Benzoyl peroxide

Benzoyl peroxide wash, lotion, or gel—the most effective acne treatment you can get without a prescription. It helps kill bacteria in the skin, unplug oil ducts, and heal pimples. There are a lot of different brands and different strengths (2.25% up to 10%). The gel may dry out your skin and make it redder than the wash or lotion, so try the wash or lotion first.
How to use benzoyl peroxide

• Start slowly—only once a day with a 5% wash or lotion. After a week, try using it twice a day (morning and night) if your skin isn’t too red or isn’t peeling.
• Don’t just dab it on top of your pimples. Apply a thin layer to the entire area where pimples may occur. Avoid the skin around your eyes.
• If your acne isn’t any better after 4 to 6 weeks, try a 10% lotion or gel. Use it once a day at first and then try twice a day if it doesn’t irritate your skin.

Stronger treatments

• Retinoid. If benzoyl peroxide doesn’t get your zits under control, your doctor may prescribe a retinoid to be used on the skin (like Retin A, Differin, and other brand names). This comes in a cream or gel and helps unplug oil ducts. It must be used exactly as directed. Try to stay out of the sun (including tanning salons) when taking this medicine. Retinoids can cause your skin to peel and turn red.
• Antibiotics, in cream, lotion, solution, or gel form, may be used for “inflammatory” acne (when you have red bumps or pus bumps). Antibiotics in pill form may be used if the treatments used on the skin don’t help.
• Isotretinoin (brand names are Accutane, Amnesteem, Sotret, and Claravis) is a very strong medicine taken as a pill. It’s only used for severe acne that hasn’t responded adequately to other treatments. Because it’s such a powerful drug, it must never be taken just before or during pregnancy. There is a danger of severe or even fatal deformities to unborn babies. Patients who take this medicine must be carefully supervised by a doctor knowledgeable about its usage, such as a pediatric dermatologist or other expert in treating acne. Isotretinoin should be used cautiously (and only with careful monitoring by a dermatologist and psychiatrist) in patients with a history of depression. Don’t be surprised
  if your doctor requires a negative pregnancy test, some blood tests, and a signed consent form before prescribing isotretinoin.

Remember

The following are things to keep in mind no matter what treatment you use:

• Be patient. Give each treatment enough time to work. It may take 3 to 6 weeks or longer before you see a change and 12 weeks for maximum improvement.
• Be faithful. Follow your program every day. Don't stop and start each time your skin changes.  Not using it regularly is the most common reason why treatments fail. 
• Follow directions. Not using it correctly can result in treatment failure or troublesome side effects.
• Only use your medicine. Doctors prescribe medicine specifically for particular patients. What's good for a friend may not be good for you.
• Don't overdo it. Too much scrubbing makes skin worse. Too much benzoyl peroxide or topical retinoid creams can make your face red and scaly. Too much oral antibiotic may cause side effects.
• Don't worry about what other people think. It's no fun having acne, and some people may say hurtful things about it. Try not to let it bother you. Most teens get some acne at some point. Also remember that acne is temporary, and there are a lot of treatment options to keep it under control.

Healthy Active Living for Families

Healthy nutrition starts as early as infancy with breastfeeding. Once your baby begins eating solid foods, introduce nutritious foods early on and often. Sometimes toddlers need to try a food 10 times before they actually accept and enjoy it. It is also important to encourage play time as soon as they start crawling and walking. As your children grow, continue to help them live a healthy active lifestyle.
To lead a healthy active life, families can strive to reach these goals:

• 5 fruits and vegetables a day,
• 2 hours or less of screen time (TV, computer, video games) per day,
• 1 hour of physical activity a day, and
• 0 limit sugar-sweetened drinks.

To help children live healthy active lives, parents can:

• be role models themselves by making healthy eating and daily physical activity the norm for their family.
• create a home where healthy choices are available and encouraged.
• make it fun - find ways to engage your children such as:
• playing a game of tag,
• cooking healthy meals together,
• creating a rainbow shopping list to find colorful fruits and vegetables,
• go on a walking scavenger hunt through the neighborhood, or
• grow a family garden.

In addition to 5, 2, 1, 0, families can make small changes in their family routines to help everyone lead healthier active lives. Try:

• Eating breakfast every day;
• Eating low-fat dairy products like yogurt, milk, and cheese;
• Regularly eating meals together as a family;
• Limiting fast food, take out food, and eating out at restaurants;
• Preparing foods at home as a family;
• Eating a diet rich in calcium; and
• Eating a high fiber diet.

Help your children form healthy habits now. Healthy active children are more likely to be healthy active adults!

Fruit Juice and Your Child's Diet

Children can easily drink a lot of juice because juice tastes good. However, too much juice in your child’s diet can contribute to other problems, like poor nutrition, obesity, and tooth decay. Parents can continue to offer age-appropriate servings of juice in addition to offering whole fruits and other beverage options like water or low-fat milk.

AAP Daily Juice Recommendations

Age	Recommendation
Younger than 6 months	Do not give fruit juice to infants younger than 6 months since it offers no nutritional benefit at this age.
1 to 6 years	Limit juice to 4 to 6 ounces per day. For children older than 6 months, fruit juice offers no nutritional benefits over whole fruits. Whole fruits also provide fiber and other nutrients. Do not allow your child to carry a cup or box of juice throughout the day.
7 to 18 years	Limit juice to 8 to 12 ounces per day

*The AAP recommends breastfeeding as the sole source of nutrition for your baby for about 6 months. When you add solid foods to your baby’s diet, continue breastfeeding until at least 12 months. You can continue to breastfeed after 12 months if you and your baby desire. Check with your child's doctor about vitamin D and iron supplements during the first year.