With vaccinations and new data, many medical recommendations and best practices surrounding COVID-19 are evolving, including guidance on sports participation and returning to sports post illness. The American Academy of Pediatrics (AAP) recently updated their COVID-19 Interim Guidance: Return to Sports and Physical Activity at the end of January. The American Medical Society for Sports Medicine (AMSSM) and National Federation of State High School Associations (NFHS) also recently released similar updated guidance on cardiopulmonary considerations specifically for high-school athletes. The AAP interim guidance applies to all children and adolescents returning to physical activity like free play, organized sports or physical education in school, and includes information about family considerations, the benefits of physical activity, transmission mitigation strategies, and specific guidelines about returning to sports after a COVID-19 diagnosis.
New cohort research studies in athletes have reported a lower incidence (0.5 percent – 3 percent) of myocarditis than found earlier in the pandemic, however, cardiac involvement remains a concern when returning to sports and physical activity. If a patient is asymptomatic or only mildly symptomatic (< 4 days of fever >100.4, < 1 week of myalgia, chills, and lethargy), the AAP recommends an assessment by a primary care physician either via telemedicine, phone or in person. Along with providing appropriate isolation and illness guidelines, this assessment should include targeted cardiac screening questions including any history of chest pain, shortness of breath, new-onset palpitations, or syncope. Any positive signs or symptoms would warrant an in-office visit and possibly an EKG prior to allowing a return to physical activity. For children with moderate symptoms, an in-office evaluation is recommended along with an EKG. An additional evaluation by a cardiologist is recommended if there are any positive screening questions or the EKG is abnormal. Children and adolescents with severe COVID-19 symptoms including an ICU stay and/or intubation or multisystem inflammatory syndrome in children [MIS-C] should be restricted from exercise for a minimum of 3-6 months and be evaluated by a cardiologist prior to returning to activity.
The AAP does recommend a gradual return to sports progression after COVID-19 infection. All athletes should be a minimum of 1-day symptom free prior to starting physical activity and should follow CDC guidance for isolation and masking, even while active. All families should be given instructions to monitor for signs and symptoms suggesting myocarditis with increased activity that would prompt further cardiac work up. Children under 12 can generally progress back to activities at their own tolerance. Adolescents who are 12 and older, who were asymptomatic or had mild symptoms should gradually increase their activity over 3 days, while those with moderate symptoms should take 5 days to increase activity prior to game participation.
All these organization recommend revising the pre-participation physical exam and history forms to include questions regarding COVID-19 vaccine status and illness history, including severity and any new cardiac symptoms. For the Minnesota State High School League, athletes are required to have a PPE every 3 years and submit an annual health questionnaire that now includes COVID-19 specific questions.
AAP COVID-19 Interim Guidance: Return to Sports and Physical Activity https://www.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/clinical-guidance/covid-19-interim-guidance-return-to-sports/ (Last updated 2/18/2022)
Cardiopulmonary Considerations for High School Student-Athletes During the COVID-19 Pandemic: Update to the NFHS-AMSSM Guidance Statement by Jonathan A. Drezner, William M. Heinz, Irfan M. Asif et. al. https://www.nfhs.org/sports-resource-content/nfhs-sports-medicine-position-statements-and-guidelines/ (Last updated January 2022)
About the Author:
Sarah Kinsella, MD, CAQ, FAAP, was recently elected to a three-year term on the AAP Council on Sports Medicine and Fitness Executive Committee. Dr. Kinsella currently practice at M Health Fairview Orthopedics in Blaine.