Okay, so this doesn’t even touch on whether or not we should be allowing youth sports in the United States during a major surge in COVID-19 – but there are still plenty of youth basketball, hockey, volleyball, etc,. games going on all around us. If children test positive we won’t be clearing them to return in the ED, but that doesn’t mean that parents and patients won’t ask. Remember, these are just recommendations and are based off of practice at many centers and on the AAP guideline. Consult with your local hospital and Cardiology groups for up to date information. This is intended for any young person (21 and under) who tests positive for COVID-19 and wants to return to sports. It is structured based on the severity of initial presenting symptoms.

Asymptomatic or mild symptoms

In general this includes patients with fewer than 4 days of fever (>100.4°F), myalgias, chills, or fatigue. As well as those with only mild upper respiratory and/or GI symptoms. These children should undergo a 14-point preparticipation screening evaluation by their primary care doctor with specific focus one the following symptoms; new chest pain, shortness of breath out of proportion for the upper respiratory symptoms they have, palpitations, or syncope. If the patient has. normal physical exam and evaluation then no testing is recommended and they can return to sports 10 days from the positive test and AND 24 house without any symptoms. Any patient with a concerning history or physical exam should be referred to pediatric cardiology for EKG and further evaluation.

How should return to play be implemented specifically?

Per the AAP, a stepwise approach supervised by the primary care doctor is safe and reasonable. The stepwise approach is as follows. If a patient fails any stage, they should remain there until they can tolerate activity. These symptoms can be monitored via telemedicine of course. Parents and patients will need to know how to monitor heart rate and what normals are.

  • Stage 1 – 2 days – 15 min or less of light activity, no greater then 70% max heart rate. No resistance training
  • Stage 2 – 1 day – 30 minutes of activity or less. Patients may add simple movement activities (running drills), reaching no greater than 80% of max heart rate.
  • Stage 3 – 1 day – 45 minutes of activity or less. Patients can introduce more complex training including the addition of light resistance training with a goal of no greater than 80% max heart rate.
  • Stage 4 – 2 days – 60 minutes of activity or less. In general this is normal training activity but no greater than 80% max heart rate.
  • Stage 5 – Return to full activity and participation in sports.

Moderate Symptoms

This includes children with ≥4 days of fever (>100.4°F), myalgias, chills, or fatigue – as well as those who had a non-ICU admission. These patients should also have no evidence of multi system inflammatory syndrome in children. All of these children should be referred to a pediatric cardiologist for EKG and evaluation. the cardiologist will determine further testing and clearance which would be no sooner than 10 days following the positive test and 24-hours of no symptoms. 

Severe Symptoms

This includes patients who were admitted to the ICU and those who required mechanical ventilation or non-invasive positive pressure ventilation. It also includes anyone who has an established MIS-C diagnosis. These patients should be followed closely by pediatric cardiology and restricted from exercise for three to six months. 

What about other tests? Can’t I order an EKG then send to cardiology?

Depending on your practice environment getting an EKG then referring to cards would be fine. Additional studies they may deploy include;

  • Troponin
  • Echocardiogram
  • Holter
  • Exercise Stress Test
  • Cardiac MRI

References

COVID-19 Interim Guidance: Return to Sports. American Academy of Pediatrics. December 17, 2020. https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/clinical-guidance/covid-19-interim-guidance-return-to-sports/. Accessed 12/23/2020.