AAP: Even COVID-Exposed Kids Need a Time-Out on Sports

American Academy of Pediatrics (AAP) interim guidance on return to sports for kids after exposure or infection with SARS-CoV-2 may be overly cautious in trying to protect their hearts, some cardiologists argued.

The guidance, last updated September 19 and expected to be replaced before December, didn't advocate routine pre-participation screening for infection for asymptomatic children not known to have been exposed.

For any children who have had COVID-19 or been exposed to it, though, the AAP recommended waiting at least 14 days before returning to exercise or competition.

Severe COVID-19: In these cases, defined by cardiac or kidney complications, invasive ventilatory support, or multisystem inflammatory syndrome in children (MIS-C), the group advocated treating as if the child has myocarditis and restricting exercise and sports participation for 3 to 6 months. After that, these kids need to be cleared by their primary care physician and an "appropriate pediatric medical subspecialist, preferably in consultation with a pediatric cardiologist." Cardiac testing, which could include cardiac MRI "if warranted," needs to normalize before return to activity, the AAP argued.

Moderate COVID-19: These cases were not defined by the AAP, but likely would mean those for whom hospitalization was at least considered but no ICU care was required, according to Christopher Snyder, MD, pediatric cardiologist at University Hospitals in Cleveland, and one of the authors of the guidance.

These kids should have COVID-19 symptoms cleared up for at least 14 days, and be cleared by their primary care physician, before return to exercise and competition. Any cardiac symptoms, concerning findings on examination, or prolonged fever should prompt an ECG and possibly pediatric cardiologist referral.

Mild or Asymptomatic Infection or Close Contact Exposure: The guidance cited "growing literature about the relationship between COVID-19 and myocarditis" in recommending a minimum 14-day resting period without symptoms before returning to exercise or competitive sports.

Even asymptomatic COVID-19 cases were recommended for pre-participation clearance by a primary care physician focusing on cardiac symptoms, "including but not limited to chest pain, shortness of breath, fatigue, palpitations, or syncope."

Striking the Right Balance

These recommendations overall are more cautious than those for adults, Snyder told MedPage Today. There are more than 20 million kids over the age of 12 in sports in the U.S., he pointed out. Even if life-threatening arrhythmias are an uncommon post-COVID risk, "nobody wants any kids to experience sudden cardiac death," he said.

"In general, I do think it is better to err on the side of caution in this setting of a lack of definitive data," agreed Kevin Friedman, MD, of Boston Children's Hospital, who is a member of the American Heart Association Young Hearts Council, but who was not involved with the AAP guidance.

"Every organization, the American Academy of Pediatrics included, is probably trying to do their level best at providing appropriate guidance in sort of uncharted territory with moving targets and fluctuating knowledge," commented Michael Ackerman, MD, PhD, director of the Genetic Heart Rhythm Clinic at the Mayo Clinic in Rochester, Minnesota.

Which parts of the AAP guidance are gross overreactions won't be clear until looked at retrospectively, he noted, but argued that ceasing all activity for 14 days "is a step taken way too far based upon essentially no data."

The AAP guidance didn't cite the specific evidence used to inform it, but Snyder pointed to autopsy data and two cardiac MRI (CMR) studies that have controversially been used for collegiate and professional sports decisions.

Ackerman, who has argued against shutting down the football season based on the CMR data, called the German CMR series "utterly irrelevant to children and adolescents" and the Ohio State athlete data meaningless without a control group.

"What's the weight of evidence that compels such a dramatic cardiopulmonary engine shutdown? I respectfully disagree," he said, speculating that the interim guidance would be adjusted soon.

Thinking has shifted on sports and exercise for kids with genetic predisposition to arrhythmia and sudden cardiac death, Ackerman noted. Where once they were automatically disqualified, "over the past 20 years, we have sort of challenged that thinking and said 'Why are we unilaterally rendering this disqualification?'" Shared decision-making with patients and their families has not led to "unacceptable" risk exposure, he noted.

"That experience has helped us slow down in trying to decide when are we becoming too restrictive in our recommendations when the evidence base just doesn't permit it," he said.

Overall, the recommendations are "quite problematic" and "carry real risk of creating more harm than benefit," cautioned Venkatesh Murthy, MD, PhD, a radiologist at the Frankel Cardiovascular Center of the University of Michigan in Ann Arbor who also has been critical of the cardiac MRI evidence for post-COVID myocarditis in recent studies.

"Given obesity, hypertension, diabetes & cardiovascular disease are consistent risk factors for COVID, it seems to me that we should be cautious in advice that could decrease physical activity," he tweeted.

Friedman was less concerned: "For the no symptoms/mild symptom COVID 19 patients, 2 weeks would be the duration they should be out of school anyways for infection control reasons, so keeping them out of sports for 2 weeks seems reasonable. I would be reluctant to hold children with mild or no symptoms out longer than that without a good reason, because we certainly don't want to encourage a sedentary lifestyle or stigma that exercise is dangerous."

Snyder acknowledged the risk that some kids won't go back if sports or exercise are taken away for a period of time. "That will not bode well for their future," he said. But it's worth it: "The most important thing is that we don't know what we don't know; and I think trading a life to allow kids to go back out there sooner would be wrong. If one kid dies on a football field...then we have lost our battle as pediatricians."

But he noted that the guidelines have been getting less restrictive as they are reworked every month and a half or so with new data emerging. "We need to watch the science," he stated.

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