Playing With Heart: Returning Kids Safely to Sport in the COVID-19 Era

Early on in the pandemic, doctors discovered that COVID-19 has a major impact on the cardiovascular system, even in the pediatric population, with reports emerging of what became known as the multisystem inflammatory syndrome in children (MIS-C). What those risks mean for getting kids back to playing sports as the COVID-19 crisis continues—and what role, if any, ECG can play in preparticipation screening—remains unclear.

Complicating matters is the high proportion of young people who never have symptomatic infections; to date, it’s not clear in these instances whether subclinical myocarditis or other myocardial damage might have occurred, putting them at risk during physical activity.

The situation provides new fodder for the broader debate around universal ECG screening for children and teens before they start playing sports. In the few places where that’s been implemented, the focus had been on finding rare underlying heart problems to prevent the tragic stories of young athletes collapsing from sudden cardiac arrest during competition.

Gul Dadlani, MD (Nemours Children’s Hospital, Orlando, FL), said COVID-19 should change considerations around universal ECG screening. “It reinforces the need for it because now you have student-athletes more at risk of myocarditis than they were a year ago and no mandatory screening process for how to go about that,” he told TCTMD.

Though recommendations from the American Academy of Pediatrics (AAP) and the American College of Cardiology (ACC) call for ECGs in patients with cardiovascular symptoms after COVID-19, “school districts don’t have any processes in place on how to do that,” Dadlani said.

But efforts should be made to broaden ECG capabilities, Dadlani indicated. “If you were the mom or dad of a student returning to school, what would you want for your child? And I think that’s how you have to look at it because this is a controversial topic when you look across the United States.”

If you were the mom or dad of a student returning to school, what would you want for your child? Gul Dadlani

When a student-athlete collapses, he said, “it’s devastating to watch and you know as a medical provider that many of those cases are preventable, but we just didn’t look. And that’s the hard part—we know we can prevent it, but we’re not acting on it. If we can do it for a low cost with reliable methods and with minimal man power issues to the school district, why not do it? If you can save even one life, then it was worth it.”

Sean Lang, MD (Cincinnati Children’s Hospital Medical Center, OH), however, said he doesn’t think COVID-19 has really shifted thinking around universal ECG screening in young athletes. “I don’t know of anyone that has been an aborted sudden death that was proven to be due to myocarditis secondary to COVID,” he said. “Now, we hope that never is the case, but as of right now we’re continuing to gather information and so far that hasn’t seemed to change the community’s recommendations with regards to this.”

What the Guidance Says

Several groups have put out recommendations on safely returning to sports in the time of COVID-19. That includes leadership from the ACC’s sports and exercise cardiology section, which initially issued guidance in May. They updated their recommendations last week.

Though the update includes a discussion of younger athletes, the initial return-to-play guidance did not address the pediatric population. In recognition of the need to address this issue specifically in youths, who have been relatively spared from severe COVID-19 compared with adults, a group of pediatric cardiologists issued a perspective on the ACC’s website in July.

“The question of returning to sports is significant because of the propensity for COVID-19 to cause cardiac damage and myocarditis,” Peter Dean, MD (UVA Children’s Hospital, Charlottesville, VA), and colleagues write. “While the incidence of myocarditis is lower in the pediatric population compared to the adult population, myocarditis is known to be a cause of sudden death during exercise in the young athletic populations. Similar to other forms of myocarditis, providers caring for patients who have had a COVID infection should be confident there is no myocardial injury prior to clearing athletes to participate.”

They outline an algorithm for clearing students for sports based on symptom level, saying asymptomatic or mild illnesses should be treated like other viral infections in the pediatric population. Lang said they’ve been following this advice at Cincinnati Children’s Hospital. After about 14 days of being symptom-free, kids are generally clear for participating in activities, he said.

For those with moderate symptoms, age comes into play, Lang said. If the athlete is 12 or older, they’d do an ECG and physical exam and if both were normal and symptoms were resolved, then they’d be clear to resume sports. For kids younger than 12, “since their exertional level during sports is likely not significantly higher than their activities of daily living, we do not believe cardiac testing is required to clear them for physical activity or sports if their history and exam are reassuring,” Dean et al write.

In patients with severe COVID-19—those who required hospitalization, had abnormal cardiac testing during the acute infection, and/or had MIS-C—then they would be handled like other pediatric patients in whom myocarditis was suspected. “These patients will have likely had cardiac testing during the acute phase (echocardiograms, ECGs, etc). Depending on the results of these, based on care of athletes with myocarditis, the patient should be restricted for 3 to 6 months and only resume activities when/if cardiac testing (ECG, echocardiogram, 24-hour Holter monitor, exercise stress test, and possibly cardiac magnetic resonance imaging) have normalized,” Dean et al write.

The recently updated ACC guidance introduces an age-based threshold. “For those younger than 15 years recovering from moderate to severe COVID-19 infection, we recommend formal evaluation with general pediatrics (or pediatric cardiology) prior to return to play to determine the need for CV risk stratification,” the authors write.

“To date, for high school athletes 15 years or older, there has been no compelling evidence of clinically relevant CV pathology following asymptomatic to mild COVID-19 infection. Thus, we recommend, in the absence of systemic symptoms or persistent CV complaints, CV risk stratification is unnecessary after CDC-recommended self-isolation,” they continue. “However, for athletes in this age group with systemic or CV symptoms during or after infection, we recommend a similar approach to athletes of older ages in competitive sports and close observation for MIS-C. In our opinion, isolated ECG screening after COVID-19 infection is of limited value because of the limited sensitivity for the detection of myocarditis (47%).”

The AAP Perspective

The AAP has weighed in as well, saying that how student-athletes are cleared for sports depends on whether they have had a positive SARS-CoV-2 test result and the severity of any COVID-19 symptoms. Those who never tested positive will be screened using the standard process, which involves a physical exam and history taking assisted by a 14-item checklist covering things like chest pain, history of elevated blood pressure, family history of cardiac disease, and presence of a heart murmur; routine ECG is not recommended.

“Every kid who participates in any kind of competitive sports should have a preparticipation physical examination with that questionnaire done, regardless of COVID or not,” Christopher Snyder, MD (University Hospitals Rainbow Babies & Children’s Hospital, Cleveland, OH), chair of the AAP’s section on cardiology and cardiac surgery, told TCTMD.

The AAP’s interim guidance on returning to sports during the time of COVID-19, last updated in the middle of September, acknowledges that there are still limited data on the effects of COVID-19 on children and adolescents and provides recommendations stratified by severity.

Those with severe presentations or MIS-C “must be treated as though they have myocarditis and restricted from exercise and participation for a duration of 3 to 6 months,” the authors write. “These athletes must be cleared to resume participation by their primary care physician and appropriate pediatric medical subspecialist, preferably in consultation with a pediatric cardiologist.” Listing the same forms of testing recommended by the ACC, the AAP recommends a return to activity only if tests come back normal.

For young athletes with moderate symptoms, the AAP recommends that they be free of symptoms for at least 14 days and obtain clearance before returning to exercise and competitive sports. “Any individual who has current or a history of positive cardiac symptoms, who has concerning findings on their examination, or who had moderate symptoms of COVID-19, including prolonged fever, should have an EKG performed and potentially be referred to a pediatric cardiologist for further assessment and clearance.”

But for others, including those with milder cases of COVID-19 or those with close contact with someone with COVID-19, the path is less clear. “Because of the growing literature about the relationship between COVID-19 and myocarditis, all children and adolescents with exposure to SARS-CoV-2, regardless of symptoms, require a minimum 14-day resting period and must be asymptomatic for > 14 days before returning to exercise and/or competition,” the AAP guidance states. “Because of the limited information on COVID-19 and exercise, the AAP strongly encourages that all patients with COVID-19 be cleared for participation by their primary care physician. The focus of their return to participation screening should be for cardiac symptoms, including but not limited to chest pain, shortness of breath, fatigue, palpitations, or syncope.”

The 2-week waiting period after symptoms resolve “might get less as we learn more about this disorder, but currently we’re conservative,” Snyder said. “We’re waiting for 2 weeks after their COVID test comes back without symptoms, then we would recommend that that child check in with their primary care physician and that primary care physician should run them through that preparticipation screening again.”

We did not learn about pandemic medicine when we were in medical school. Christopher Snyder

Guidance developed by pediatric specialists at Nemours Children’s Hospital are largely consistent with the AAP’s advice. Patients “want to ensure that all their cardiovascular symptoms have completely resolved before they return to sports,” Dadlani said, noting that the vast majority of kids with a positive test result aren’t going to have CV symptoms suggestive of myocarditis. “All these recommendations are really being set up to ensure that those kids in the smaller group get caught so that they don’t step back on the field with active heart inflammation.”

Snyder pointed out that these recommendations are fluid and can change as more is learned about COVID-19. “We did not learn about pandemic medicine when we were in medical school. Nobody did. And nobody has ever seen COVID-19 until 2019,” he said. “And so we don’t know what we don’t know.”

Physicians should continue evaluating young athletes “knowing that there is an extremely small risk of that child developing myocarditis,” Snyder added. “But even then, it’s an extremely small risk of that child having any untoward events. And so I would say that if they’re screened through their primary care doc and their primary care doc says they’re okay, then they’re okay.”

COVID-19 and Universal ECG Screening

Whether athletes of any age should be screening routinely with ECG before sports participation has long been an area of controversy. Universal ECG screening is not mandated at the national level in the United States, but it is in a few countries, including Israel and Italy.

Such a strategy can catch many—but not all—forms of cardiac disease that can lead to sudden cardiac death, Dadlani noted. It is very sensitive for detecting the leading cause of sudden death, which is hypertrophic cardiomyopathy.

Opponents to universal preparticipation ECG screening in the United States, Dadlani pointed out, have cited several potential obstacles, including cost, man power issues, challenges with getting reliable readings from qualified interpreters, access to follow-up in case of abnormal findings, and false-positive results that could unnecessarily sideline youth from healthy activities.

However, a study presented at the AAP’s virtual meeting in October by Dadlani’s group suggests that, at least at a local level, widespread preparticipation ECG screening is possible. For the effort, the school system in Brevard County, FL, partnered with Who We Play For, a nonprofit foundation that “brings affordable, efficient, and noninvasive heart screenings to communities across the country,” according to the group’s website. Dadlani is on the medical advisory team for the foundation.

The program was able to screen 5,877 students, and 97% of ECGs were normal. Overall, the study identified eight students (0.1%) who had critical heart disease with a risk of sudden cardiac arrest. “But those were eight student-athletes who could have passed away,” Dadlani said, noting that with full capture of data the number probably would have been higher.

With this project, provided schools can partner with a local healthcare entity and ensure follow-up for the patients, “ECG screening within a large school district is feasible and possible for other school districts to implement on their own, even without statewide mandates or national mandates,” Dadlani said.

He suggested that studies showing evidence of cardiac damage associated with COVID-19 has revived the debate about universal ECG screening before sports participation. Cardiac magnetic resonance studies have shown signs of myocarditis in college athletes recovering from COVID-19 and even in younger, nonhospitalized patients—both studies included young people who never had symptoms. The clinical significance of these findings remains unclear.

Even though the issue of preparticipation screening has been discussed in the context of COVID-19, Lang doesn’t think the pandemic has moved the needle much. Sudden death during physical activities in young people is tragic, but “exceedingly rare,” he said.

Snyder agreed. “I think people are now obviously very nervous about COVID-19. COVID-19 has a clear-cut known inflammation of the heart, even in asymptomatic kids. I don’t know that it’s changed the overall question as to whether every kid needs an EKG or not. I have not heard that from the pediatricians.”

Something to consider, Lang added, is that it’s not possible to prevent all of these rare events from occurring. “It’s very challenging to find the needle in the haystack,” he said. The current pandemic does highlight the need for systemwide care of athletes, however. “There need to be [automated external defibrillators] in place and there need to be people who are CPR-trained in case one of these rare situations happens. And that’s not only during the pandemic, but going forward we think that having appropriately trained personnel might be the best thing to do for these rare but tragic sorts of events that happen.”

Shifting the Discussion

The discussion about universal ECG screening is likely to continue in the United States, regardless of COVID-19. “If we’re going to go to universal EKG screening, what we need is . . . a favorable climate for a rational debate,” Snyder said. “I cannot argue with a family whose child has died while playing football or basketball that every kid does not need an EKG. It is an impossible argument to have. That mother is going to say this might have saved my child, and they are right.”

It’s very challenging to find the needle in the haystack. Sean Lang

The discussion should also be shifted away from whether large-scale screening will be cost-effective toward whether it is “worth it,” Snyder said. In large metropolitan areas with plenty of ECG machines and pediatric cardiologists who can interpret the tests, a universal ECG mandate might make sense. But in a rural area where the nearest ECG machine is 100 miles away, it would be more difficult to require it, he said.

“Nobody knows the correct answer,” Snyder said. “I believe that it would save some lives for sure. It won’t save all lives. The risk of sudden cardiac death in athletes up to 36 years of age is two per hundred thousand. It is estimated that less than half of those high-intensity athletes are under the age of 18, so it’s one per hundred thousand. So, many people and insurance providers and systems would argue that one per hundred thousand isn’t worth it.”

On the other hand, he said, “we’re pediatric cardiologists. We don’t ever want to be at a football game or a basketball game and see a kid drop and have to run out onto the court and start CPR.”

There are obstacles to broader ECG screening, Snyder indicated. The disorders such screening is intended to detect are rare and even pediatric cardiologists would have a hard time identifying them on an ECG reading, so asking adult cardiologists to pitch in would be inappropriate, he said. Asking cardiologists to volunteer to interpret tests is also not sustainable, he said. “If I did outside EKGs on the side and wasn’t charging anything, I am still liable for those.”

Snyder believes the path forward for universal ECG preparticipation screening involves families and physicians sitting down together to work out these issues.

“All of us need to get together, form a group, and in my opinion, potentially lobby the federal or state government to require this to become mandatory,” Snyder said. “Having families do it is unfair to the families. Having the physicians do it is unfair to the physicians. And I think that the two groups together need to lobby to have this become mandatory. Whether it’s worthwhile or not, it will save some lives—not hundreds and thousands of lives, but it’ll save some. . . . If it saves one life, then I think the vast majority of pediatric cardiologists are for that.”