Sports Clearance for Pediatric Patients with History of COVID-19
Rationale for Return to Competition after COVID-19 Infection by Cory Noel (SCH Pediatric Cardiologist)
There is a wide variety of screening measures being conducted around the country for cardiovascular screening following COVID-19 infection. What must be acknowledged at this time is there is a paucity of information of the cardiovascular involvement in asymptomatic/mildly symptomatic patients infected, as well as within the pediatric population. There is a significant portion of hospitalized patients that demonstrate myocardial injury ranging from 7% to 23%. Myocardial involvement in hospitalized patients has shown to be a significant risk factor for mortality. While symptom onset is typically within 11 days (range of 8.2 – 15.6) of contact, myocardial involvement often appears after a more prolonged period from the onset of symptoms (up to 10-15 days after onset of symptoms). Few studies exist which investigate the myocardial involvement in asymptomatic athletes, however a recent Ohio State study conducted with cardiac MRI in 26 athletes with a mean age of 19 demonstrated evidence of myocarditis acutely in 15% and previous myocardial involvement in 30%. The MRI was conducted within these athletes after quarantine, ranging from 11 to 51 days after infection diagnosis. It is this concern regarding the unknown prevalence of cardiac involvement within asymptomatic and mildly symptomatic athletes that has caused delay and consternation in the resumption of athletics.
Outside of additional understanding of the myocardial involvement in pediatric athletes, there are several factors that influence the degree of cardiovascular evaluation such as infectious burden in the community, cardiovascular resources, and cost-effectiveness. It is this combination of factors that has lead to such variability of recommendations. In the most recent state of Alaska COVID-19 update, there have been a total of 1,017 pediatric patients aged between 10-19 years old diagnosed, with only 0.2% requiring hospitalization. There are several guidelines that recommend a more conservative approach, such as the ACC and AAP which generally recommend no additional cardiac testing in asymptomatic or mildly symptomatic pediatric athletes. However, there are several recommendations for more aggressive cardiac testing with consideration for some degree of medical evaluation and cardiac testing, primarily ECG, even in asymptomatic or mildly symptomatic patients. In addition to these more aggressive guidelines, there are several major pediatric institutions proceeding with more aggressive cardiology testing. At this time Texas Children’s Hospital and Mott Children’s Hospital at University of Michigan are recommending and have clinics available for all patients with previous COVID-19 infection. As part of the evaluation, an echocardiogram, ECG and lab evaluation is being conducted at Texas Children’s Hospital and a cardiac MRI is being performed in athletes at the University of Michigan. At Lurie Children’s hospital in Chicago, a “middle of the road” approach is being undertaken with a recommendation for all patients with mild symptoms to have a medical evaluation including an ECG and cardiology evaluation for patients with moderate symptoms or higher. This approach is also quite similar to the Sibley Heart Center at Emory University, with an attempt to minimize staff and patients from potential COVID-19 exposure that additional testing would require. At this time, the Children’s Hospital of Philadelphia appears to be the most conservative, with recommendations mirroring the ACC recommendations, with Stephen Paridon being a critical factor in the decision-making.
Given the cardiology resources within the state of Alaska, the relatively manageable amount of patients of pediatric age with the relatively low incidence of patients having documented severe illness or hospitalization, it is my recommendation that a more aggressive testing approach be undertaken at this time. This recommendation is made with the full knowledge that as more information becomes apparent, this recommendation be revisable and open to change to account for new information and optimized for pediatric care in the state of Alaska.
- Return to Play Algorithm PDF (2 pages)
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- Pirzada et al. Review: COVID-19 and Myocarditis: What Do We Know So Far?. CJC Open. July 2020.
- Graduated Return to Play Protocol Infographic
- Kim JH, Levine BD, Phelan D, et al. Coronavirus Disease 2019 and the Athletic Heart: Emerging Perspectives on Pathology, Risks, and Return to Play. JAMA Cardiol. 2021;6(2):219–227. doi:10.1001/jamacardio.2020.5890