New Guidelines for Children Returning to Sports after Covid-19

Published:January 22, 2021DOI:


      Approximately 45 million children participate in some form of athletics. The COVID-19 pandemic has affected many aspects of their lives, including sports activities. Families are asking care givers questions about how best to ensure the safety of their children when returning to sports activities. The American Academy of Pediatrics has issued revised guidelines for children returning to athletic activities after COVID-19. These include strengthening the recommendations for cloth mask wearing for all children engaging in vigorous sports and clarifications of cardiac risks to children who have had COVID-19.


      As communities begin to hold sports activities for children after the coronavirus disease of 2019 (COVID-19) pandemic, children and their families are asking their healthcare providers questions about when it will be safe for their children to return to group sports. The American Academy of Pediatrics (AAP) has published new guidelines about participation in youth sports post COVID-19 (American Academy of Pediatrics, 2020).
      The new guidelines are in response to the increasing number of COVID-19 cases in children and are designed to reduce the risk of transmission to other children, to family members and to their communities. The AAP had previously published guidelines on children and sports during the pandemic, but the new revision strengths the face mask recommendations for children engaged in vigorous sports and clarifies the cardiac risks of children who have had COVID-19. Care providers should also refer to their state regulations and guidance associated with the return to sports as states are allowing practice and competition to resume at different stages (Centers for Disease Control and Prevention, 2020a).
      The new AAP guidelines recommend that all young people wear face masks for all indoor sports. The only exceptions are swimming and diving, since it is harder to breathe through wet masks; gymnastics and cheerleading, where masks could get caught or obstruct vision; and during wrestling contact, where there could be a choking hazard. Cloth face masks should be used when athletes are competing in sports, during group training sessions, while on the sidelines, when traveling and in the locker room. Cloth face masks that completed cover the nose and mouth and are fitted on the sides with no gaps significantly reduce the transmission of COVID-19. The authors note that although it may take a couple of attempts to find a mask that they can work out in, athletes tolerate the masks well and, although the first time they may find it an annoyance, by the second or third time, they are not generally bothered by it. Specific guidelines for youth sports administrators addressing assessing community risk, modifying settings of sporting activities, limiting nonessential visitors, restricting travel to sporting events, cleaning and disinfecting sports equipment, cohorting of training groups and what to do if an athlete becomes sick after participating in a sporting event have been published by the Centers for Disease Control and Prevention (2020b).
      Heart problems have been a concern for both children and adults since early in the pandemic when it became clear that COVID-19 can cause inflammation of the heart muscles. The early recommendations for children who have had COVID-19 were very conservative with extensive testing before returning to play. As more information has become available about the impact of the COVID-19 virus on children, it has become clear that it was more important to focus on those children who were more significantly ill. The new AAP guidelines recommend that children who have asymptomatic disease or a mild form of the disease (less than 4 days of fever) need to be screened by their primary care providers before returning to play. Their primary care providers will do a cardiovascular history and physical similar to the American Heart Association's recommended 14-point screening checklist (American Heart Association, 2014). All children who have had COVID-19 should be asked about chest pain, shortness of breath, palpitations or fainting. An abnormal exam should lead to an EKG and a referral to a pediatric cardiologist.
      The AAP guidelines recommend that all children who have tested positive for the virus, including those without symptoms, should increase activity slowly after being screened. The guidelines recommend using the schedule for gradual return to play published by the British Journal of Sports Medicine last year. It recommends 5 stages of incremental increase in activity that can start after the child had had at least 10 days of rest and be symptom-free for 7 days (Elliott et al., 2020). The 5 levels of activity are based on type of activity, maximum heart rate, duration of activity, the objective of the activity and the type of monitoring required (Inforgraphic, 2020).
      Children with more severe disease, including fever for four or more days, more severe and prolonged symptoms of muscle aches, chills or lethargy, or a hospitalization, should see a cardiologist after the symptoms resolve and before starting to play. The early recommendations were based on recommendations for adults which included cardiac testing for everyone who tested positive for COVID-19, including EKG, echocardiograms and blood tests for troponins. As time has passed, it has become clear that, although some children with multisystem inflammatory syndrome, do need extensive cardiac workups, cardiac complications among children who are mildly ill are extremely rare and the focus should be on those who had moderate or severe disease or who have persistent symptoms. As more has been learned about the possible effects of COVID-19 on the pediatric heart, the concern about subclinical myocarditis for children with mild disease has been replaced with concern about viral spread and community transmission.
      There is a general recognition that sports participation has great value in the lives of children and adolescents. It can provide an outlet for children when their lives have been adversely impacted by the global pandemic. The benefits of participating in sports makes it urgent that children begin participating in athletic activities as soon as it is safe for them to do so. Care givers can help families balance the risk of children playing sports versus the risk of not playing sports.

      Declaration of Competing Interest

      The authors declare that there are no conflicts of interest.