While most children and teenagers with COVID-19 make a full recovery, the virus can sometimes have permanent effects. One of these effects can be damage to the heart muscle – and when a damaged heart is stressed from exercise, it can lead to arrhythmias, heart failure, or even sudden death.
This seems to be rare. Given that we are literally learning about COVID-19, it’s difficult for us to know how rare – and how risky, training after a positive COVID-19 test can be. To help doctors, coaches, physical education teachers, parents, and caregivers make safe decisions, the American Academy of Pediatrics has published some guidelines on returning to exercise and physical activity after COVID-19.
This is a “preliminary guide” – our best guess what to do right now based on what we know so far. Unfortunately, there is a lot we don’t know and we won’t know until we’ve had more time to study the virus and see what happens to patients as they recover over weeks, months, and years.
What is important to know about returning to exercise and physical activity?
Teenagers and young adults who participate in competitive sports are at the highest risk of developing a heart problem. This is both because younger children appear to be less affected by COVID-19, and because older teens and young adults train harder, which increases the stress on the heart muscle. Of course, no one can say for sure that walking around an elementary school playground is completely risk-free for a child with COVID-19.
The guidance on returning to physical activity depends on whether the case of COVID-19 has been classified as mild (including asymptomatic), moderate, or severe.
- Mild: fever greater than 100.4 for less than four days and muscle pain, chills, or fatigue for less than a week (this would include those with asymptomatic cases)
- Moderate: fever over 100.4 days for four or more days; muscle pain, chills, or tiredness for a week or more; or hospitalization (not in intensive care) with no evidence of MIS-C. (MIS-C is the multi-system inflammation syndrome that sometimes occurs with COVID-19.)
- Severe: ICU stay and / or intubation or evidence of MIS-C. During intubation, a tube is inserted through the mouth into the airway and connected to a machine to make it easier for a child to breathe.
What screening could be done after a child has recovered from an asymptomatic to mild case of COVID-19?
Providing guidance to adolescents with mild or asymptomatic cases is the hardest part as we really have limited data on this group when it comes to their heart health.
For these children, experts recommend that the parents contact the child’s primary care provider. Wait for the child to recover from their illness (or at least 10 days after a positive test if a child is asymptomatic). You should be checked for symptoms of heart problems, whichever is the most worrying
- Chest pain
- Shortness of breath, which is more than you would expect from a cold
- Palpitations that they have never had
- Dizziness or fainting.
A simple phone call to the doctor’s office may be sufficient for very mild or asymptomatic cases in children who are not serious athletes.
A personal exam is a good idea for those whose cases have been borderline or have any concerns, or where the child is a serious athlete.
If there are concerns about the answers to questions or the physical exam, an EKG and referral to a cardiologist are helpful.
If you’re not worried, kids are free to return to recreational physical activity at will. The return to competitive sport should be gradual, paying attention to symptoms. See the AAP guide linked above for suggestions on how to do this.
What screening could be done after a child has recovered from a moderate or severe case of COVID-19?
Any child who has had a moderate illness should have their family doctor screened for symptoms and examined. Schedule the visit at least 10 days after the child tests positive for the virus and has had no symptoms for at least 24 hours without taking paracetamol or ibuprofen.
If you have any questions or concerns about symptoms or findings on the physical exam, it is a good idea to contact a cardiologist for clearance and guidance on returning to physical activity.
It is imperative that children who have had a serious illness see a cardiologist and should be excluded from activity for at least three to six months. They won’t come back until a cardiologist says it’s okay.
Again, this is a preliminary guide that will evolve as we learn more about COVID-19 and its short- and long-term effects. If you have any questions, speak to your doctor.
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