Returning to sports and physical activity after COVID-19: What parents need to know

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While most children and teens who have COVID-19 recover completely, sometimes the virus can have lasting effects. One of those effects can be damage to the muscle of the heart — and if a damaged heart is stressed by exercise, it can lead to arrhythmias, heart failure, or even sudden death.

This appears to be rare. But given that we are literally learning as we go when it comes to COVID-19, it’s hard for us to know how rare — and just how risky exercise after testing positive for COVID-19 might be. To help doctors, coaches, gym teachers, parents, and caregivers make safe decisions, the American Academy of Pediatrics has published some guidance on returning to sports and physical activity after having COVID-19.

This is “interim guidance” — our current best guess about what to do, based on what we know so far. Unfortunately, there is much we don’t know, and can’t know until we have had more time to study the virus and watch what happens to patients as they recover over weeks, months, and years.

What’s important to know about returning to sports and physical activity?

Teens and young adults who play competitive sports are at highest risk for a heart problem. This is both because younger children appear to be less affected by COVID-19, and because older teens and young adults have harder workouts that are more likely to stress the muscle of the heart. Of course, nobody can say for certain that running around an elementary school playground is completely risk-free for a child who has had COVID-19.

The guidance for returning to physical activity depends on whether the case of COVID-19 was considered mild (including asymptomatic), moderate, or severe.

  • Mild: fewer than four days of fever greater than 100.4, and less than one week of muscle aches, chills, or fatigue (this would include those with asymptomatic cases)
  • Moderate: four or more days of fever greater than 100.4; a week or more of muscle aches, chills, or fatigue; or a hospital stay (not in the ICU) with no evidence of MIS-C. (MIS-C is the multisystem inflammatory syndrome that sometimes occurs with COVID-19.)
  • Severe: any ICU stay and/or intubation, or evidence of MIS-C. During intubation, a tube is placed through the mouth into the airway and connected to a machine to help a child breathe.

What screening might be done after a child recovers from an asymptomatic to mild case of COVID-19?

It’s toughest to offer guidance for youths who have had mild or asymptomatic cases, as we truly have limited data on this group when it comes to the health of their hearts.

For these children, experts recommend that parents check in with the child’s primary care provider. Wait until the child has recovered from their illness (or at least 10 days after a positive test if a child is asymptomatic). They should be screened for any symptoms of heart problems, with the most worrisome being

  • chest pain
  • shortness of breath that is more than you’d expect after a bad cold
  • palpitations that they have never had before
  • dizziness or fainting.

A simple phone call to the doctor’s office may be sufficient following very mild or asymptomatic cases in children who aren’t serious athletes.

An in-person examination is a good idea for those whose cases were more borderline, or if there are any concerns at all, or if the child is a serious athlete.

If there are any worries based on the answers to questions or the physical examination, then an EKG and a referral to a cardiologist make sense.

If there aren’t any worries, then children can return to recreational physical activity as they feel able. Returning to competitive sports should be done gradually, watching for symptoms along the way. See the AAP guidance linked above for suggestions on how to do this.

What screening might be done after a child recovers from a moderate or severe case of COVID-19?

Any child who had a moderate illness should see their primary care provider to be screened for symptoms and examined. Schedule the visit at least 10 days after the child had a positive test for the virus, and has had no symptoms for at least 24 hours without taking any acetaminophen or ibuprofen.

If there are any questions or worries at all about symptoms or a finding on the physical examination, referral to a cardiologist for clearance and guidance about returning to physical activity is a good idea.

Children who have had severe illness absolutely need to see a cardiologist, and should be restricted from activity for a minimum of three to six months, only returning when a cardiologist says it’s okay.

Again, this is interim guidance that will evolve as we learn more about COVID-19 and its short- and long-term effects. If you have questions, talk to your doctor.

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