AAP updates guidance on returning to sports/activity after COVID-19

Editor’s note: For the latest news on COVID-19, visit https://bit.ly/AAPNewsCOVID19.

How should pediatricians evaluate patients who want to return to sports or physical
activities after COVID-19 infection? Should kids wear a mask during athletic practices
and games?

The updated AAP COVID-19 Interim Guidance: Return to Sports and Physical Activity addresses these questions based on the growing understanding of SARS-CoV-2 infection,
increased number of fully vaccinated individuals as young as 12 years and a drop in
COVID-19 cases and deaths in the U.S.

The AAP guidance on face masks is consistent with Centers for Disease Control and
Prevention (CDC) guidance. A face mask may not be necessary for all sport-related
activities. But for those keeping score:

  • Everyone should consider wearing a mask in crowded indoor spaces such as locker rooms
    and shared transportation, regardless of their vaccination status.
  • Athletes who are not fully vaccinated should wear face masks when on the sidelines
    at outdoor sports and during all group training and competition when there is sustained
    contact of 3 feet or less. They also should wear a mask when arriving at or departing
    from the playing facility and off the playing field.
  • Proper use of a face mask for all indoors sports training, competition and on the
    sidelines is strongly recommended for those who are not fully vaccinated, except when
    the mask is a safety risk.
  • Unless fully vaccinated, coaches, officials, spectators and volunteers should wear
    a mask.

“Sports performed outside are lower risk for transmission of SARS-CoV-2, and a face
mask may not be necessary for all sport-related activities,” according to the guidance.

Mitigation strategies such as wearing a face mask (when appropriate) can reduce transmission
rates for indoor sports to as low as outdoor sports. Exceptions to mask-wearing might
be appropriate when the risk of heat-related illness is increased.

Return to activity after infection

The guidance includes new information on evaluating patients for resumption of physical
activity or sports after testing positive for SARS-CoV-2. Pediatricians should have
patients notify them if they test positive for SARS-CoV-2 and document the infection
in the medical record.

  • For patients with asymptomatic or mildly symptomatic COVID-19 illness: A phone or
    telemedicine visit is recommended, at a minimum. Recent studies report a lower incidence
    of myocarditis (0.5{066dbc63777e5ed549f406789d72fdeebd77a32711d57f7b38ff2b35c4ba2a42} to 3{066dbc63777e5ed549f406789d72fdeebd77a32711d57f7b38ff2b35c4ba2a42}) from SARS-CoV-2 infection, than reported earlier in the
    pandemic. However, myocarditis has been reported in patients with asymptomatic or
    mildly symptomatic illness. Therefore, pediatricians should ask about chest pain,
    shortness of breath out of proportion for upper respiratory tract infection, new-onset
    palpitations or syncope. Any reports of these symptoms warrant an in-office visit,
    physical examination and consideration of EKG before clearing the patient to return
    to physical activity.
  • For patients with moderate symptoms and no evidence of multisystem inflammatory syndrome
    in children (MIS-C): An in-person evaluation by the primary care pediatrician is recommended.
    Patients should not exercise until cleared, and the evaluation should occur after
    symptoms have resolved and quarantine is completed. The guidance recommends reviewing
    the American Heart Association 14-element screening evaluation with emphasis on cardiac
    symptoms, complete physical examination and EKG. Next steps depend on cardiac screening
    or EKG findings.
  • For children with severe COVID-19 symptoms or MIS-C: AAP guidance remains unchanged.
    These children should forgo exercise for at least three to six months and receive
    cardiology clearance before resuming training or competition.

Further workup is not required for children who had SARS-CoV-2 infection and have
returned to physical activity or sports on their own and do not have any abnormal
signs or symptoms.

Health supervision visits

At the annual health supervision visit and preparticipation physical evaluation, pediatricians
can provide guidance on gradual return to physical activity if the patient has recovered
from COVID-19 and has not participated in consistent physical activity for more than
a month. This includes:

  • Starting at 25{066dbc63777e5ed549f406789d72fdeebd77a32711d57f7b38ff2b35c4ba2a42} of usual volume and intensity of activity and consider exercising
    every other day.
  • Increasing volume by 10{066dbc63777e5ed549f406789d72fdeebd77a32711d57f7b38ff2b35c4ba2a42} each week until desired volume is reached.
  • Increasing intensity by 10{066dbc63777e5ed549f406789d72fdeebd77a32711d57f7b38ff2b35c4ba2a42} each week until desired intensity is reached.

Finally, the AAP encourages COVID-19 vaccination for all eligible people. An athlete
who is fully vaccinated can follow CDC transmission mitigation recommendations for
vaccinated people.


Sports checklist for parents from HealthyChildren.org, https://bit.ly/3xaCiFm

Copyright © 2021 American Academy of Pediatrics

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