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COVID-19 & Sports: What are we doing for sports clearance?

As kids resume sports, more and more questions arise...

Are sports safe?

Which sports are better?

What precautions should I be taking?


What I tell my parents is to first thoroughly understand the risks vs benefits when deciding if a child should play sports during the pandemic. There are many variables to consider, and there is no easy answer. A great starting point is the following article: Youth Sports and COVID-19: Understanding the Risks. Always discuss your specific case with your pediatrician.


As we learn more about COVID-19 and how it affects children and young adults, a concern is cardiac injury in children with COVID-19 infection. This is particularly meaningful when it comes to sport clearance and participation.


The mechanism of cardiac injury due to COVID-19 infection STILL REMAINS UNCLEAR!


Speculations include:

  • Cytokine mediated cardiomyopathy

Substances released by our immune system that cause enlargement of the heart

  • Demand ischemia

The heart needs more oxygen than is available by the body at that moment

  • Acute coronary syndrome

Reduced blood flow to the heart that causes injury to the heart tissue

  • Myocarditis from myocyte invasion by the virus

Our immune system produces cells to fight the virus but these cells release chemicals and these chemicals can cause inflammation of the heart muscle


Ok... I don't understand all that medical jargon, what do I need to know???


When the heart tissue is injured it can lead to abnormalities in the pumping ability of the heart or its ability to relax (such as with left ventricular dysfunction)

Injury to the heart tissue can also affect the normal electrical conductivity of the heart or how the heart beats (such as the case with arrhythmias)


This is a very generalized view of a very very complex topic


What would my Pediatrician worry about???


I'm particularly worried about viral myocarditis (inflammation of the heart muscle caused by exposure to the virus) as this can lead to potentially fatal arrhythmias (irregular heart rhythm) posing a risk to athletes


Return to exercise after myocarditis has to be approached with caution as myocarditis accounts for 7-20% of sudden cardiac deaths (SCD) in young athletes (Ref 1-3)


So how common is this???


To date, up to 25% of hospitalized patients with COVID-19 exhibit significant cardiac manifestations including left ventricular dysfunction and arrhythmias (Ref 4)

which exceeds the about 1% prevalence of cardiac involvement in non-COVID-19 acute viral infections (Ref 5)


Is there a way to detect this issue of myocarditis and heart injury???


We can use an ECG/EKG (electrocardiogram) to detect some changes

A cardiologist can also perform more specific testing if warranted


An ECG is a fancy word for a test that measures the electrical activity of the heart

This test uses electrodes that are placed on the chest

It's quick and easy with no pain or discomfort

Fun fact: For those of you with an apple watch you may be able to get a simple reading with the ECG app, this is not diagnostic and you should consult your health provider if any irregularities are detected


Understand that the statistics above are from limited data, still evolving and continue to change regularly as new information arises


Emphasizing that the information we currently have is still evolving and changing


There are large gaps in our current knowledge base that will fill as we learn more, this will take time


A POSITIVE: Most children and young adults are asymptomatic with COVID-19 infection


The above data is from hospitalized patients, meaning patients that got very ill from COVID-19


So how is Head2Toe Pediatrics currently screening young athletes and clearing for sports?

- As of October 2020 -


Below is general guidance for what we are doing to clear children and young adults for sports participation. Bear in mind that all things are fluid and this can change at any moment. Talk to Dr. Lastra to discuss your specific situation.


The above is general guidance for patients of Head2Toe Pediatrics

Always discuss your medical concerns and specific scenarios with your healthcare provider

Additional reading and information:

AAP COVID-19 Interim Guidance: Return to Sports

ACC Exercise and Athletics in the COVID-19 Pandemic Era


References:

  1. Phillips M, Robinowitz M, Higgins JR, Boran KJ, Reed T, Virmani R. Sudden cardiac death in Air Force recruits. A 20-year review. JAMA 1986;256:2696-9.

  2. Eckart RE, Scoville SL, Campbell CL, et al. Sudden death in young adults: a 25-year review of autopsies in military recruits. Ann Intern Med 2004;141:829-34.

  3. Maron BJ, Haas TS, Ahluwalia A, Murphy CJ, Garberich RF. Demographics and epidemiology of sudden deaths in young competitive athletes: from the United States National Registry. Am J Med 2016;129:1170-7.

  4. Driggin E, Madhavan MV, Bikdeli B et al. Cardiovascular considerations for patients, health care workers, and health systems during the COVID-19 pandemic. J Am Coll Cardiol 2020;75:2352-71.

  5. Fung G, Luo H, Qiu Y, Yang D, McManus B. Myocarditis. Circ Res 2016;118:496-514.

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