There are new guidelines for children, especially high school children, for returning to competitive sports after COVID-19 infection. These guidelines are likely to change as we learn more, as with everything else related to the new coronavirus. Some children with COVID-19 develop heart inflammation, which may or may not have any symptoms. Experts currently believe that heart inflammation poses a risk to athletes. Children can be screened for heart inflammation with an ECG.

Clearance for return

The recommendations differ in their guidance on which children need to be screened with an ECG. Some base it on age of patient, and most base it on severity of disease as well. Some guidelines state that all athletes with COVID-19 need to be cleared by a physician to return to play, and others only those children who need an ECG need to be cleared for return.

I have discussed the current guidelines with Henry County Schools and asked about their policy; I am awaiting an answer (9/5/20). I have not discussed it with the private schools in the county. We have not yet been asked to clear any students to start or to return to play after infection as the current guidelines would suggest.

Here are Georgia’s current guidelines:

The GHSA states risk or concern (symptoms) and positive test: “It is currently recommended that returning to sport after a positive test is determined by the team physician or other appropriate healthcare provider. Individuals should consult a healthcare provider before returning to physical activity and follow the Georgia Department of Public Health’s “Return to School Guidance After COVID-19 Illness or Exposure” https://dph.georgia.gov/document/document/return-school-guidance/download

Positive test and no symptoms: “should consider seeking clearance from your healthcare provider prior to return to play. If you develop symptoms after testing positive, follow the Georgia Department of Public Health’s “Return to School Guidance After COVID-19 Illness or Exposure” https://dph.georgia.gov/document/document/return-school-guidance/download

National Federation of State High School Associations (NFHS) and American Medical Society for Sports Medicine (AMSSM) recommends ALL students complete a covid questionnaire prior to starting play and if positive, get clearance from a medical provider, and if had disease, get clearance from medical provider. It also advises considering an ECG in mild cases, and full cardiology evaluation in more severe cases.

The American Academy of Pediatrics (AAP) currently recommends all who have had COVID-19 be cleared by a physician prior to returning to sports, and rest for 2-4 weeks prior to starting the return process.

Sibley Heart Center/Children’s Healthcare of Atlanta (CHOA) recommends a modified approach that includes all children, not just athletes or older children. They recommend that all children with serious disease, and those with moderate disease (symptoms 3 or more days or any fever) have an ECG.

Gradual return

As with concussion, returning to sports after COVID-19 should be done in a gradual fashion, watching for any symptoms as you move through the stages. There is still much we do not know about COVID-19 and lingering effects on the body. It does currently appear that there is a risk in some patients of temporary heart disease; children should not return to sports if there is any evidence of heart problems.

Student athletes must complete progression through the stages without developing any of the following symptoms: chest pain, chest tightness, pain radiating to the left arm or shoulder, shoulder pain, passing out (syncope), almost passing out (near syncope), feeling lightheaded, dizziness, irregular heart rhythm (palpitations). If any symptoms develop, stop exercise/sports and see your child’s doctor.

  • First, 2 weeks rest after symptoms have resolved. Then:
  • Stage 1: two days minimum. light activity (walking, jogging, light exercise bike) 15 minutes, less than 70% max heart rate, no resistance training
  • Stage 2: 1 day minimum: may add simple drills, 80% max heart rate, 30 minutes
  • Stage 3: 1 day minimum more complex drills, 80%, 45 minutes, light resistance training
  • Stage 4: 2 days minimum normal training 60 minutes 80%
  • Stage 5: full activity

References & Resources

Missouri State High School Activities Association has a nice return to play form here.

Kansas has a good preseason clearance form.

American Academy of Pediatrics COVID-19 Interim Guidance: Return to Sports

Drezner JA, Heinz WM, Asif IM, et al. Cardiopulmonary Considerations for High School Student-Athletes During the COVID-19 Pandemic: NFHS-AMSSM Guidance Statement. Sports Health. Published online July 9, 2020:194173812094149. doi:10.1177/1941738120941490

Elliott N, Martin R, Heron N, Elliott J, Grimstead D, Biswas A. Infographic. Graduated return to play guidance following COVID-19 infection. Br J Sports Med Epub ahead of print: 22-06-2020. doi:10.1136/bjsports-2020-102637

Stearns RL, Scarneo-Miller SE, Huggins RA, Baker LB, Caterisano T. Return to Sports and Exercise during the COVID- 19 Pandemic: Guidance for High School and Collegiate Athletic Programs.

Returning To Play After Coronavirus Infection: Pediatric Cardiologists’ Perspective. American College of Cardiology. Accessed September 5, 2020. http%3a%2f%2fwww.acc.org%2flatest-in-cardiology%2farticles%2f2020%2f07%2f13%2f13%2f37%2freturning-to-play-after-coronavirus-infection

Phelan D, Kim JH, Chung EH. A Game Plan for the Resumption of Sport and Exercise After Coronavirus Disease 2019 (COVID-19) Infection. JAMA Cardiol. Published online May 13, 2020. doi:10.1001/jamacardio.2020.2136