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Children should not return to sports for 14 days after exposure to COVID-19, and those with moderate symptoms should undergo an electrocardiogram (ECG) before returning, according to the American Academy of Pediatrics (AAP).
The recommendations, which update the academy’s July 23 guidance, stem from new concerns that the disease can cause myocarditis, said Susannah Briskin, MD, a pediatric sports medicine specialist at Rainbow Babies and Children’s Hospital in Cleveland, Ohio.
“There has been emerging evidence about cases of myocarditis occurring in athletes, including athletes who are asymptomatic with COVID-19,” she told Medscape Medical News.
The update aligns the AAP recommendations with those from the American College of Cardiologists, she said.
Recent imaging studies have turned up signs of myocarditis in athletes recovering from mild or asymptomatic cases of COVID-19 and have prompted calls for clearer guidelines about imaging studies and return to play.
Viral myocarditis poses a risk to athletes because it can lead to potentially fatal arrythmias, Briskin said.
Although children benefit from participating in sports, these activities also put them at risk of contracting COVID-19 and spreading it to others, the guidance notes.
To balance the risks and benefits, the academy proposed guidelines that vary depending on the severity of the presentation.
In the first category are patients with a severe presentation (hypotension, arrhythmias, need for intubation or extracorporeal membrane oxygenation support, kidney or cardiac failure) or with multisystem inflammatory syndrome.
Clinicians should treat these patients as though they have myocarditis. Patients should be restricted from engaging in sports and other exercise for 3 to 6 months, the guidance states.
These athletes’ primary care physician and “appropriate pediatric medical subspecialist, preferably in consultation with a pediatric cardiologist,” should clear them before they return to activities.
In examining patients for return to play, clinicians should focus on cardiac symptoms, including chest pain, shortness of breath, fatigue, palpitations, or syncope, the guidance says.
In another category are patients with cardiac symptoms, those with concerning findings on examination, and those with moderate symptoms of COVID-19, including prolonged fever. These patients should undergo an ECG and possibly be referred to a pediatric cardiologist, the guidelines say.
These symptoms must be absent for at least 14 days before these patients can return to sports, and the athletes should obtain clearance from their primary care physician before they resume, the academy says.
In a third category are patients who have been infected with SARS-CoV-2 or who have had close contact with someone who was infected but who have not themselves experienced symptoms. These athletes should refrain from sports for at least 14 days, the guidelines say.
Children who don’t fall into any of these categories should not be tested for the virus or antibodies to it before participation in sports, the academy says.
The guidelines don’t vary depending on the sport. But the academy has issued separate guidance for parents and guardians to help them evaluate the risk for COVID-19 transmission by sport.
Athletes participating in “sports that have greater amount of contact time or proximity to people would be at higher risk for contracting COVID-19,” Briskin said. “But I think that’s all fairly common sense, given the recommendations for non-sport-related activity just in terms of social distancing and masking.”
The new guidance calls on sports organizers to minimize contact by, for example, modifying drills and conditioning. It recommends that athletes wear masks except during vigorous exercise or when participating in water sports, as well as in other circumstances in which the mask could become a safety hazard.
They also recommend the use of hand-washing stations or hand sanitizer, avoiding contact with shared surfaces, and avoiding small rooms and areas with poor ventilation.
Briskin has disclosed no relevant financial relationships.
American Academy of Pediatrics. COVID-19 Interim Guidance: Return to Sports. Full text
Laird Harrison writes about science, health, and culture. His work has appeared in magazines, newspapers, and online publications. He is at work on a novel about alternate realities in physics. Visit him at lairdharrison.com or follow him on Twitter: @LairdH.