COVID-19 sports participation recommendations

In the era of COVID-19, there have been many questions and concerns surrounding the risks of returning to exercise and sports participation following COVID infection. Given the increased rate and severity of infection in the adult community, the recommendations for cardiac evaluation prior to exercise and sports participation are understandably extensive. The approach in the pediatric population, however, should reflect the severity of infection and the risk of long term cardiopulmonary compromise.

As there is a significantly lower prospect of symptoms and sequelae in the pediatric population, the evaluation prior to sports participation should reflect this decreased risk appropriately. Accordingly, the pediatric algorithm for returning to sports differs from that in the adult community. Included below is the algorithm for evaluation and monitoring of pediatric patients following COVID-19 infection in determining their clearance for sports participation.

Summary of Recommendations:

All patients should be symptom free for at least 10 days prior to any sports participation.

Asymptomatic patients (tested positive or are presumed positive) and athletes with mild symptoms or symptoms that last less than four days

Should refrain from sports participation for at least 10 days from known infection. If asymptomatic, may return to sports following evaluation by pediatrician. Pediatrician evaluation should include cardiac-related questions including evaluation for history of syncope, near syncope, dizziness, angina or palpitations during exercise. Additionally, physical exam should include evaluation of blood pressure and resting heart rate, as well as auscultation for presence of arrhythmia, new-onset murmur or other abnormal cardiac sounds.

Cardiology evaluation should be sought if pediatrician feels this is warranted.

Pediatric patients with moderate symptoms (such as four or more days of fever, cough, myalgia, chills, lethargy, or for any non-ICU hospital admission and no evidence of MIS-C)

Should refrain from sports until symptom free for a minimum of 10 days. Can return to play after cardiac evaluation with ECG prior to sports clearance. May require further testing (echocardiogram, troponin, etc.) based on cardiac evaluation and ECG results.

Pediatric patients with severe symptoms (required hospitalization, especially if suspected multisystem inflammatory syndrome (MIS-C), abnormal cardiac testing during illness)

Recommendation is to follow more conservative myocarditis return to play guidelines.

3-6 months of recovery time prior to returning to exertional activities and sports.
Close monitoring with resumption of activities only after cardiac evaluation and testing (ECG, echocardiogram, 24-hour Holter monitor, stress testing, possible cardiac MRI) has normalized.
Patients may require more frequent cardiac evaluations and for a more prolonged period of time both prior to and during their return to sports and physical activities.

Guidance provided by UT Southwestern, Pediatric Heart Specialists and Pediatric Cardiology Associates of Houston physicians.