American Academy of Pediatrics Sports Recommendations During COVID-19 (click here for the full article)

What to do if a participant had COVID-19 or has it during the season?

Mild Infection: In a SARS-CoV-2–positive child who is either asymptomatic or mildly symptomatic (<4 days of fever >100.4°F, short duration of myalgia, chills, and lethargy), there are limited data available and recommendations are based on expert opinion. Individuals who test positive for COVID-19 should not exercise until they are cleared by a physician. It is suggested they visit with their primary care physician (PCP) who will review the local 14-point preparticipation  screening evaluation with special emphasis on cardiac symptoms including  chest pain, shortness of breath out of proportion for upper respiratory tract infection, new-onset palpitations, or syncope and perform a complete physical examination. If the preparticipation  screening   evaluation and examination are  normal, no further testing is warranted and the patient may begin a gradual return to play after  10 days have passed from date of the positive test result and a minimum of 24 hours symptom free off-fever reducing medications. If the PCP identifies any new or concerning history or physical examination findings at this visit, an ECG should be performed and referral should be made to a pediatric cardiologist for evaluation and further testing. 

Moderate Infection: For those with moderate symptoms of COVID-19 (≥4 days of fever >100.4°F, myalgia, chills, or lethargy or those who had a non-ICU hospital stay and no evidence of MIS-C ), an ECG and cardiology consult is currently recommended after symptom resolution, and at a minimum of 10 days past the date of the positive test result. Individuals who test positive for SARS-CoV-2 should not exercise until they are cleared by a physician. The cardiologist may consider ordering a troponin test and an echocardiogram at the time of acute infection. Depending on the patient’s symptoms and their duration, additional testing including a Holter monitor, exercise stress testing, or cardiac magnetic resonance imaging (MRI) may be considered. If cardiac workup is negative, gradual return to physical activity may be allowed after 10 days have passed from the date of the positive test result, and a minimum of 10 days of symptom resolution has occurred off fever-reducing medicine.  

Severe Infection: For patients with severe COVID-19 symptoms (ICU stay and/or intubation) or multisystem inflammatory syndrome in children (MIS-C), it is recommended they be restricted from exercise for a minimum of 3 to 6 months and definitely require cardiology clearance prior to resuming training or competition. Coordination of follow-up cardiology care should be arranged prior to hospital discharge. Extensive cardiac testing should include but is not limited to: troponin tests, echocardiogram, and cardiac MRI. 

A graduated return-to-play protocol can begin once an athlete has been cleared by a physician (cardiologist for moderate to severe COVID-19 symptoms) and is asymptomatic when performing normal activities of daily living. The progression should be performed over the course of a 7-day minimum. Consideration for extending the progression should be given to athletes who experienced moderate COVID-19 symptoms as outlined above.