Originally Published: on Dec. 4, 2020 | New York Times | By Perri Klass, M.D.
Children and adolescents who want to return to sports after having the coronavirus should be cleared by a doctor for heart risks.
The American Academy of Pediatrics posted updated guidance Friday on young people and sports in the pandemic, making a strong recommendation that participants should wear face masks for all indoor sports. It made exceptions only while swimming and diving, since it’s harder to breathe through wet masks; during gymnastics and cheerleading, where masks could get caught or obstruct vision; and during wrestling contact, where they could be a choking hazard.
Cloth face masks are also encouraged for outdoor sports, when athletes are competing, in group training sessions and on the sidelines. The new recommendations are a response to rising numbers of Covid-19 cases in children and are meant to protect the athletes themselves, their family members and their communities.
The academy had issued previous guidance on children and sports in the pandemic, but this revision notably strengthens the face mask recommendations for those actually engaged in vigorous exercise, and offers clarifications on cardiac risks for young athletes who have had Covid-19.
“We know kids are getting infected at a significant rate, we know kids live with adults and there’s a significant rate of transmission if they bring it home,” said Dr. Susannah Briskin, an associate professor of pediatric sports medicine at Rainbow Babies and Children’s Hospital in Cleveland, who is on the executive committee for the American Academy of Pediatrics’ council on sports medicine and fitness, and was co-author on the new guidance.
Dr. Briskin said that in states that have mandated masks for all sports, “athletes tolerated the change very well — most people take a couple of practices to find a mask they can work out in.” When she was working on the guidance, Dr. Briskin started exercising in a mask herself, and tried several kinds to find the right one. It may take more than one session to get used to wearing the face mask during exercise, she said. “The first time, people may find it to be an annoyance; by the second or third, they don’t notice,” she said.
Heart problems after Covid-19 have been a concern in athletes, both children and adults, since early in the pandemic, when it became clear that the novel coronavirus could cause myocarditis, or inflammation of the heart muscle. So the advice has been adjusted for young athletes who have had Covid-19 and want to return to play.
The new A.A.P. guidance specifies that children and adolescents who have had asymptomatic disease or mild disease need to be screened by their primary care providers before returning to sports. Those who have not been sick, or who have had less than four days of fever and other mild symptoms, should see their regular doctors, who are expected to carry out a cardiovascular history and physical (the American Heart Association recommends a 14-point screening checklist).
All those who have had Covid-19, even without symptoms, should thus be asked about symptoms like chest pain, shortness of breath, palpitations or fainting. A positive screen or an abnormal physical exam should lead to an EKG and a referral to a pediatric cardiologist. And a child or adolescent who had a more significant bout with Covid-19 — including fever for four days or more; more severe and prolonged symptoms of muscle aches, chills or lethargy; or a hospitalization — should see a cardiologist after symptoms resolve and before starting to exercise.
Even those who were completely asymptomatic should increase activity gradually, and only after being screened, Dr. Briskin said, suggesting five stages of incremental progress toward full activity; the A.A.P. recommends a schedule for graduated return to play that was published in the British Journal of Sports Medicine earlier this year.
Dr. Aaron Baggish, the director of the cardiovascular performance program at Massachusetts General Hospital Heart Center, said that early in the pandemic, when it became clear that many of those who were sick enough to be admitted to the hospital with Covid had evidence of injury to the heart, those who worked with athletes began worrying about what they might see in young people.
Early guidelines were very conservative, he said, and recommended extensive testing, but more recently, with better information, it has become clear that it is more important to focus on those who were more significantly ill. Dr. Baggish was the senior author of an article, “Coronavirus Disease 2019 and the Athletic Heart,” published in October in the journal JAMA Cardiology, which put forth guidance for cardiac testing in adult athletes before they can return to play. The article also argued that while there are still many unknowns about the possible effects of Covid-19 on the heart, the single most important consideration about organized sports should be preventing transmission and viral spread.
Dr. Briskin agreed that the initial approach pediatricians took, when not much was known about the effects of Covid-19 infection, to “make sure we were doing everything we could to protect our athletes,” advice was generally to be very conservative. “We’re just starting to hit the point where we’re getting some data about cardiac effects of Covid-19 on a younger population,” she said; “that’s going to help us give more accurate guidance for return to play.”
Dr. Peter Dean, a pediatric cardiologist who is the team cardiologist for University of Virginia athletes, and who sits on the American College of Cardiology sports and exercise leadership committee, said that as far back as June, athletes who had had Covid were starting to ask if they could go back to playing. The recommendations for adults at the time suggested fairly extensive cardiac testing for everyone, including EKGs, echocardiograms and blood tests for troponins (proteins that increase when there is injury to heart muscle).
“At that point we really weren’t seeing pediatric cases,” Dr. Dean said, and it seemed that children were less severely affected by the infection in general. Covid-19 infection can definitely affect the heart in a child or adolescent, Dr. Dean said, and some children, such as those with multisystem inflammatory syndrome, do need extensive cardiac work-ups. But rather than testing all children, it makes sense to focus on those who had moderate or severe disease, or who have persistent symptoms.
“Myocarditis is a big deal, but it’s incredibly rare,” he said.
“I think we are less worried as a community now about subclinical myocarditis than we were before,” Dr. Dean said. There was a fear, perhaps, that children who had been mildly ill might have sudden cardiac arrests, either at home or when exercising, but “we just haven’t seen it.”
Dr. Alex Diamond, the director of the program for injury prevention in youth sports at Vanderbilt University Medical Center, said that the conversation about returning to play after even asymptomatic Covid infection should be “another opportunity for pediatricians to have a touchpoint with their patients.”
Because of the pandemic, he said, “we’re seeing people delaying care for other issues,” and missing well child checks and vaccinations. The sports physical allows the pediatrician to do all the other important checks to make sure that a child or adolescent is doing well and can safely participate in sports.
And anyone who continues to have symptoms after Covid, especially shortness of breath, palpitations or chest pain, should be seen promptly by a doctor. “Watch out for any exertional type symptoms,” Dr. Diamond said.
Sports have great value in the lives of children and adolescents, and people who practice sports medicine tend to believe strongly in the benefits of athletic participation. “Our kids need some outlets, their lives have been turned completely upside down, like the rest of us,” Dr. Diamond said. “For some, their only outlet is sports.” But the benefits of exercise make it even more urgent to make things as safe as possible.
“When we talk about the risk of playing sports, we have to look at the risk of not playing sports,” Dr. Dean said.
Contact sports bring people close together, Dr. Briskin said, and as sports move indoors for the winter, the risk of transmission increases. “If people want to give sports a chance to continue in a safe manner, they need to give thought how to do it safely and curtail spread before we see lots of teams isolated or people infected,” Dr. Briskin said. In addition, the athletes need to restrict their activity away from sports, she said, again minimizing their own risks and reducing community spread.