Paeds · rheumatology-musculoskeletal-and-sports
Performance-enhancing substances in young athletes
Also known as doping in young athletes · anabolic steroid use in adolescents · performance and image enhancing drugs · PIEDs · ergogenic aid use in children · WADA prohibited substances · sports supplement misuse · androgen abuse in the young athlete · unintentional doping from supplements
A fellowship approach to performance-enhancing substances in the young athlete: the WADA prohibited list and the principle of strict liability, the anabolic steroids that dominate illicit use and the cardiovascular, hepatic, endocrine, and psychiatric harm they inflict on a still-growing body, the supplements that work and the contaminated supplements that trigger inadvertent positive tests, and the non-judgemental, evidence-based counselling that prevents use.
On this page
Study tools
Your progress
Saved on this device.
Practise this topic
Target exams
Red flags
- Rapid gains in lean mass with severe acne, gynaecomastia, testicular atrophy, or new stretch marks in an adolescent boy is anabolic-androgenic steroid use until a focused, confidential history proves otherwise
- A young athlete who becomes suddenly aggressive, irritable, or depressed, particularly around gym cycles, may be in the manic or withdrawal phase of androgen use and must be asked directly and privately
- Chest pain, palpitations, syncope, or a new murmur in a young strength athlete demands evaluation for the cardiomyopathy, dyslipidaemia, and hypertension that androgens accelerate
- A positive doping test can follow a single contaminated over-the-counter supplement, because strict liability holds the athlete responsible for every substance found in their sample regardless of intent
- Cessation of androgens precipitates a hypogonadal withdrawal that can drive suicidal ideation, so stopping must never be abrupt or unsupported
- Adolescent androgen use accelerates epiphyseal fusion through aromatisation to oestrogen and can reduce final adult height, an irreversible harm unique to the young athlete
Life stages
Care settings
Clinical exam formats
Board mappings
- Adolescent medicine - screen for performance and image enhancing drug use using a confidential, developmentally appropriate history
- Musculoskeletal medicine - recognise the physical signs of anabolic-androgenic steroid use in the young athlete
- Growth and Development - explain how androgens accelerate epiphyseal fusion and may reduce final adult height
- Adolescent medicine - the WADA prohibited list, the principle of strict liability, and the role of the clinician in anti-doping
- Mental health - the psychiatric and dependence sequelae of androgen use and the safe, supported withdrawal pathway
- Renewed curriculum for first-year trainees from 2027 - Learning goal 6: Clinical management - essential general paediatrics
- Adolescent medicine 10-12
- Mental health and behaviour 10-12
- Clinical Applications
- Short Cases
- Long Cases
- 12. Adolescent health including substance use and the young athlete
- 8. Musculoskeletal and sports medicine including ergogenic aid use
- 4. Professional skills and knowledge: Health promotion and prevention
- Foundation of Practice (FOP)
- Theory and Science (TAS)
- Applied Knowledge in Practice (AKP)
- Clinical
- History
- Communication
- Video
- General Pediatrics Content Outline - Adolescent Medicine: substance use and performance-enhancing substances
- General Pediatrics Content Outline - Sports Medicine: ergogenic aids and the young athlete
- General Pediatrics Content Outline - Universal Task 5: Patient Management
- Patient Care 4: Clinical Reasoning
- Patient Care 5: Patient Management
- Medical Knowledge 2: Conditions common in pediatric primary care including adolescent substance use
- Systems-Based Practice 2: Coordinated acute and chronic care
- Pediatrics: Adolescent medicine applied domain
- Pediatrics: Sports medicine and ergogenic substance use
A fifteen-year-old opens the consultation with a sore shoulder, but the real story is in his body: he has gained nine kilograms of lean mass in a term, his back and shoulders are covered in cystic acne, his testicles are small for his stage of puberty, and he admits, only when you ask alone and without his father in the room, that he has been injecting testosterone and an oral steroid he bought online for the last four months. You do not lecture him. You acknowledge the effort he has put in, you explain what the drugs are doing to his growth plate and his heart, you arrange baseline bloods, and you plan a slow, supported taper with a mental-health safety net, because abrupt cessation can precipitate a depressive crash. [6] [7]
PERFORM
Ask the young athlete alone and confidentially. Prescription and over-the-counter medications, including inhalers and any tablets bought online. Ergogenic supplements, from protein and creatine to pre-workout and thermogenic fat-burners. Recreational drugs, alcohol, and nicotine, which interact with sporting and cardiovascular risk. Feelings and mental health, because the mood swings, irritability, and low mood of androgen cycles and withdrawal are the hidden harm. Outcomes and pressure, the sources of performance and appearance pressure that drive use. Route and regimen, the dose, frequency, injection practice, and sharing of equipment that govern blood-borne virus risk. Motivation, what the athlete hopes to achieve, because meeting that goal safely is the alternative you offer. [6] [7]
Overview & Definition
Performance-enhancing substances are agents taken with the intention of improving sporting performance, body composition, or appearance, and they span a spectrum from permitted ergogenic aids such as creatine and caffeine through to prohibited androgenic hormones and blood manipulations. The fellowship candidate holds the spectrum in mind rather than reaching for the single word "steroids", because the adolescent in front of the clinician may be using anything from a whey protein shake to a vial of injectable testosterone bought without a prescription. The clinical task is to find out which, to gauge the harm, and to intervene proportionately. [1] [7]
Two frameworks organise the field for the clinician. The first is the World Anti-Doping Agency prohibited list, which governs competitive athletes and defines which substances and methods are banned in and out of competition. The second is the wider public-health category of appearance- and performance-enhancing drugs and substances, which captures the non-competitive adolescent who uses androgens, growth hormone, or image-enhancing drugs for the mirror rather than the medal. The young athlete often sits in both frameworks at once, and the clinician who forgets the second misses the gym-using teenager who will never be drug-tested. [10] [4]
The paediatric and adolescent dimension is what makes this a distinct topic from adult sports medicine. The adolescent is still growing, so the gonadal suppression and the premature epiphyseal fusion carry an irreversible cost the adult does not pay. The adolescent brain is still maturing, so the mood, impulse-control, and dependence risks carry greater weight. And the adolescent is forming identity and habits, so a non-judgemental, harm-reducing intervention at this window can redirect a trajectory that a punitive response would only drive underground. [6] [7]
References11ShowHide
- [1]Calfee R, Fadale P. Popular ergogenic drugs and supplements in young athletes. Pediatrics, 2006.PMID 16510635
- [2]Nieper A. Nutritional supplement practices in UK junior national track and field athletes. British Journal of Sports Medicine, 2005.PMID 16118303
- [3]Irving LM, Wall M, Neumark-Sztainer D, Story M. Steroid use among adolescents: findings from Project EAT. Journal of Adolescent Health, 2002.PMID 11927236
- [4]Sagoe D, Molde H, Andreassen CS, Torsheim T, Pallesen S. The global epidemiology of anabolic-androgenic steroid use: a meta-analysis and meta-regression analysis. Annals of Epidemiology, 2014.PMID 24582699
- [5]Goldberg L, Elliot D, Clarke GN, MacKinnon DP, Moe E, et al. Effects of a multidimensional anabolic steroid prevention intervention. The Adolescents Training and Learning to Avoid Steroids (ATLAS) Program. JAMA, 1996.PMID 8918852
- [6]Mulcahey MK, Schiller JR, Hulstyn MJ. Anabolic steroid use in adolescents: identification of those at risk and strategies for prevention. The Physician and Sportsmedicine, 2010.PMID 20959703
- [7]Holland-Hall C. Performance-enhancing substances: is your adolescent patient using? Pediatric Clinics of North America, 2007.PMID 17723868
- [8]Jovanov P, Đorđić V, Obradović B, et al. Prevalence, knowledge and attitudes towards using sports supplements among young athletes. Journal of the International Society of Sports Nutrition, 2019.PMID 31272457
- [9]Kozhuharov VR, Ivanov K, Ivanova S. Dietary Supplements as Source of Unintentional Doping. BioMed Research International, 2022.PMID 35496041
- [10]Ganson KT, Alebraheem Z, Coelho J, Fournier C, et al. Appearance- and Performance-Enhancing Drugs and Substances Use Among Adolescents: Physician Reports. Academic Pediatrics, 2026.PMID 41724323
- [11]Edenfield KM. Sports Supplements: Pearls and Pitfalls. Primary Care, 2020.PMID 32014135