The doctors, including UVA Health’s Peter Dean, MD, say that in most cases – especially asymptomatic cases – children should be able to return to sports two weeks after recovering. But they warn against a one-size-fits-all approach, especially for youths who get very sick, and they stress the importance of ensuring recovering student-athletes cannot spread the disease further.
“COVID-19 has been shown to cause significant heart damage in adults, and because of this, the adult guidelines are recommending several cardiac tests before returning to sports and physical activity,” said Dean, a cardiologist at UVA Children’s. “Fortunately, since children seem to be less impacted by COVID-19 and their level of exercise intensity is less, pediatric providers should be able to more easily clear patients without extensive cardiac testing in mild cases.”
In addition to Dean, the new guidance comes from Lanier Burns Jackson, MD, of Medical University of South Carolina, and Stephen M. Paridon, MD, of Children’s Hospital of Philadelphia. (Dean and UVA Health’s Robert Battle, MD, have been working with the UVA Sports Medicine team led by John MacKnight, MD, to clear UVA athletes to return to participation after COVID-19 infections.)
COVID-19 and Cardiac Damage
The guidance is meant for physicians but will have important implications for many families this fall. Most COVID-19 cases in children are mild or asymptomatic, the doctors note, but severe cases can occur. In those cases, doctors and families must proceed cautiously.
“The question of returning to sports is significant because of the propensity for COVID-19 to cause cardiac damage and myocarditis,” a serious heart inflammation, the authors write for the American College of Cardiology’s website, ACC.org. “While the incidence of myocarditis is lower in the pediatric population compared to the adult population, myocarditis is known to be a cause of sudden death during exercise in the young athletic populations.”
In the rare case when a child or teen is hospitalized, has abnormal cardiac tests during the infection or suffers “multisystem inflammatory syndrome in children” caused by COVID-19, more cardiac testing is required, the doctors say. Such children may need to be kept out of sports for three to six months, and they should only return to the field if cardiac testing and other metrics come back normal, the cardiologists advise.
Children who have mild infections, on the other hand, should be able to return to practice two weeks after their last symptoms disappear. “Patients should be asymptomatic for at least two weeks,” the doctors emphasize. “This two-week period will allow for the full clinical manifestations of COVID-19 to present themselves and, perhaps most importantly, decrease the risk of transmitting the infection to teammates or opponents.”
In the middle of the spectrum are pediatric patients who have “moderate” symptoms of COVID-19 but do not become seriously ill. These are children and teens who may have prolonged fevers, for example. Doctors need to assess these patients on a case-by-case basis, and they should consider the type and intensity of sports the patients play. “Providers should not treat the 7-year-old recreational soccer player the same as the 18-year-old varsity basketball player,” the cardiologists say.
High-school and college athletes who have moderate COVID-19 symptoms may warrant cardiac testing before returning to the field, but younger children likely will not, the doctors advise.
As a precautionary measure, the cardiologists recommend that youth sports and high-school athletics programs ensure defibrillators, CPR and medical care are available during sporting events.
“Most pediatric patients should be fairly easily cleared to resume sports after a COVID-19 infection, but there will be rare cases where more extensive cardiac testing is required,” Dean said. “We also expect to learn more about the long-term cardiac implications of the virus in the next several months to years, so it is important to stay up-to-date with information.”
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