COVID-19 has changed almost all aspects of our lives over the past year. Now, when we head out the door, in addition to remembering our wallet or purse and keys, we must remember a mask and hand sanitizer. Our ability to have birthday parties for our kids has changed and our ability to eat indoors is now controlled by the distance tables are spaced apart and our vaccination status… it has changed everything. For kids, one area that COVID-19 has changed, is returning to sports participation. We now have to consider a number of factors before determining when and if a child is safe to return to these activities.
You are likely wondering why and how COVID-19 illness affects sports participation. Though in our experience, most children with COVID-19 infection are either asymptomatic or very mildly ill, this virus still has the propensity “to cause cardiac damage and myocarditis” (inflammation of the heart muscle). And, though myocarditis is much less commonly observed in children than it is in adults, its consequences can be devastating, causing sudden death during exercise. Though this consequence is one we hope no family ever faces, it is rare, and we have guidelines to help us determine when and if a child needs screening for this condition before being cleared to return to contact sports participation. “When considering the question of return-to-play, we believe there are three variables to consider: (1) How recent was the COVID-19 infection? (2) How severe was the infection? (3) What is the physical activity or sport being considered?” We will explore these more below.
Time since infection
“All patients who have been infected with SARS-CoV-2 or with exposure to SARS-CoV-2, regardless of symptoms, require a minimum 14-day resting period and must be completely asymptomatic for greater than 14 days before returning to exercise and/or competition. They also should be cleared for participation by their primary care physician.” Additionally, based on their illness symptoms and any findings of cardiac abnormalities on physical examination, the primary care provider will determine if referral to a pediatric cardiologist for additional evaluation and testing is warranted.
Illness severity - mild:
Definition: Mild infection means the child/teen was “either asymptomatic or mildly symptomatic (<4 days of fever >100.4°F, < 1 week of myalgia (muscle aches), chills, and lethargy).”
Cleared to return to exercise after: being symptom free > 14 days with evaluation by PCP who finds no abnormalities on physical exam and the child/teen reports no “chest pain, shortness of breath out of proportion for upper respiratory tract infection, new-onset palpitations, or syncope when returning to exercise.” If these symptoms were to become present, he/she should stop exercise and call the PCP.
Illness severity - moderate:
Definition: Moderate infection means the child/teen had “≥4 days of fever >100.4°F, ≥ 1 week of myalgia, chills, or lethargy, or a non-ICU hospital stay and no evidence of MIS-C (multisystem inflammatory syndrome in children).”
Cleared to return to exercise after:
- Children 11 and under: once symptom free > 14 days, with evaluation by PCP who finds no abnormalities on physical exam, and the child/teen reports no “chest pain, shortness of breath out of proportion for upper respiratory tract infection, new-onset palpitations, or syncope when returning to exercise” he/she may progress back to sports as tolerated. If these symptoms were to become present, he/she should stop exercise and call the PCP.
- Children 12 and older: once symptom free > 14 days, with evaluation by PCP who finds no abnormalities on physical exam, and with a normal EKG, the PCP may clear the child/teen to return to exercise. The exercise should occur in the form of a “graduated return-to-play protocol” which should “be performed over the course of a 7-day minimum.” The PCP may consider extending this progression for those whose illness was in the moderate category. With return to exercise, the child/teen should report no “chest pain, shortness of breath out of proportion for upper respiratory tract infection, new-onset palpitations, or syncope.” If these symptoms were to become present, he/she should stop exercise and call the PCP.
Illness severity - severe:
Definition: severe infection means the child/teen had “ICU stay and/or intubation or multisystem inflammatory syndrome in children (MIS-C).”
Cleared to return to exercise after: symptom free > 14 days with evaluation by a pediatric cardiologist who, among other things, will likely recommend “they be restricted from exercise for a minimum of 3 to 6 months and obtain cardiology clearance prior to resuming training or competition.”
Level of physical activity
The American College of Cardiology and the American Academy of Pediatrics divide children into 2 groups based on age. They feel that those under 12 years participating in contact sports typically do not exert a significantly higher level of activity in sports than their routine activities of daily living. Typically, when we think of “high intensity competitive sports participation,” we think of teenage sports participation. This is not to say that an 11 year old athlete does not run and play to the point of exhaustion, but simply that in many instances, they are highly active across the board, both in and out of sports, and that their sports participation is likely not as rigorous as that of a high school or collegiate athlete. So, why do we make a distinction between intensity of sport participation and return to play after COVID infection? We know that myocarditis can cause irregular heartbeats or weaken the heart muscle, and these findings can be worsened with high intensity exercise, which we see most in older children and teens.
We agree with you that this is scary! We also agree that COVID-19 has affected our children adversely in so many ways (changes to the way we participate in school and limiting social interactions with peers), and we hate to see COVID-19 affect our children’s extracurricular activities as well! That being said, children are resilient. We have seen time and again that they weather this illness well. Though we do have to take COVID-19 and its potential effects on our bodies seriously, we can also feel reassured that these guidelines will help us make the safest decisions in providing the best timeframe for return to sports participation after a COVID-19 infection.