Return to play after COVID-19 infection in child and adolescent athletes: should physician’s clearance always be required?

This editorial refers to ‘Cardiac screening prior to return to play after SARS-CoV-2 infection: focus on the child and adolescent athlete. A Clinical Consensus Statement of the Task Force for Childhood Health of the European Association of Preventive Cardiology’ by F. D’Ascenzi et al., https://doi.org/10.1093/eurjpc/zwac180.

Since it first appeared, the COVID-19 pandemic has dramatically impacted the health of individuals of all ages worldwide. Among other health consequences of this multisystem inflammatory novel disease, abnormalities in cardiac testing and cardiovascular complications (myocardial involvement, thrombosis, and arrhythmias) have been observed in COVID-19-infected patients. Early reports about myocardial involvement being common raised a high degree of concern,¹ especially among athletes and the sports medicine community, as several studies have found myocarditis to be one of the common causes of sudden cardiac arrest/death in athletes.² More recent studies have found that myocarditis from COVID-19 infection may be a rare complication,³ but assessing the true incidence may be challenging. Cardiac magnetic resonance (CMR) studies performed in athletes as part of the return to play (RTP) screening protocol show varying rates of imaging abnormalities due to several reasons (ambiguous definitions, differences in the studied populations and imaging protocols, etc.). Overall, present data suggest that most of the testing abnormalities (electrocardiogram, CMR, and elevated cardiac biomarkers) associated with COVID-19 infection may be related to nonspecific myocardial inflammation, but severe myocarditis cases are rare.⁴

Myocardial and/or pericardial involvement have also been reported after COVID-19 messenger RNA vaccination, with a trend towards increased risk in young males after the second vaccine dose. These findings have certainly complicated immunization efforts, but several studies have shown that they are even far less common and apparently with a not more severe clinical course than post COVID-19 infection cases.^4,5

While a large list of comorbidities have been identified as risk factors for severe COVID-19 (age ≥ 65 years, physical inactivity, obesity, smoking, asthma, diabetes, coronary artery disease, etc.), a healthy lifestyle including regular physical activity appears to be strongly associated with a lower risk of severe COVID-19 outcomes in infected adult individuals.⁶ These should certainly be considered as positive news, not only for active individuals and athletes, but also for all health professionals using exercise prescription in their daily practice as one of the best and most cost-efficient strategies in the prevention and treatment of cardiovascular and many other diseases.

Through existing evidence, we also know that young age confers a protective effect against COVID-19, as most infected children, adolescents, and young individuals tend to have asymptomatic or milder disease. While this is true, we cannot skip mentioning the devastating impact of lockdowns and other social isolation measures on the emotional well-being and mental health of the younger age groups during the pandemic. Numerous studies have observed sharp increases in the prevalence of anxiety, depression, and even self-harming behaviours as well as suicide attempts among youth.⁷ Moreover, in addition to the psychological effects of social isolation, the stay-at-home order led to a situation in which the opportunities to practice physical activity were significantly reduced in many areas of the world. There is clear evidence that participating in regular physical activity and sports practice, particularly when performed outdoors, can increase self-esteem as well as reduce anxiety and depression in children and adolescents.⁸ The increase in sedentary behaviour during the early stages of the pandemic certainly had a greater impact on these younger age groups, worsening the effects of social isolation on their emotional well-being and mental health.

To increase awareness and try to detect COVID-19-infected athletes at risk, several screening protocols have been proposed in different countries around the world. As most of the previously published protocols focus on adult athletes, the present consensus document of the Task Force for Childhood Health of the European Association of Preventive Cardiology⁹ is both relevant and pertinent because it allows the authors to highlight the most important aspects that make COVID-19 infection in the youth different from adults. As mentioned in the document, the main difference is related to the severity of the disease, because as COVID-19 infection in the paediatric population is most likely asymptomatic or mild compared with that in adults, the risk of cardiac consequences is also lower. The second and not less important aspect highlighted by the authors is the dramatic impact of the COVID-19 pandemic on the physical activity levels and mental health of youth.

There are two other important key messages included in this consensus document, directly related to the above aspects and essential when designing screening strategies. First, the need for cardiac evaluation in RTP protocols for children and adolescents should not be based on age but should be guided by the severity of disease and the presence of cardiac symptoms and second, RTP protocols should not create unnecessary barriers, which may limit physical activity levels.

While one can fully agree with these key messages, the task force recommendation requiring physician’s clearance for all children and adolescent athletes with mild symptoms or no symptoms at all, is quite controversial and could be considered needless as well as unbearable by our already overburdened healthcare systems. Nowadays, there are no solid arguments supporting that asymptomatic and mild COVID-19 in paediatric athletes should be treated differently from other common viral illnesses.

Different protocols recommend no testing and gradual retraining/RTP for COVID-19-infected athletes with either mild noncardiopulmonary (fever, cough, sore throat, malaise) or no symptoms after self-isolation.^4,10 In line with this approach, Hodgson et al.¹¹ propose a reasonable self-assessment algorithm for athletes who rely on their own means, in which those with either no history of COVID-19 infection or a history of mild infection with no cardiac symptoms during infection and currently asymptomatic for at least 7 days, could proceed with gradual retraining/RTP, without being assessed by a medical professional. Currently, asymptomatic athletes but with a prolonged illness of more than 7 days, or those with cardiac symptoms during acute infection, or with current debilitating symptoms, or hospitalized due to COVID-19, or with persistent cardiac symptoms, or with reduced performance, should always be assessed by a medical professional before RTP (Figure 1).^4,10,11

Figure 1

Proposed cardiac evaluation/referral of child and adolescent athletes prior to a gradual return to training/play after COVID-19 infection. Adapted from references.^4,10,11

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I believe that in accordance with the present situation and evidence, a more liberal approach in screening protocols for children and adolescent athletes before RTP after COVID-19 infection is feasible and needed to protect both their physical and mental health, as well as avoiding unnecessary testing and physical activity/sport restrictions.

Funding

None.

Data availability

No new data associated with this invited editorial.

References

Author notes