Thread by @venkmurthy

Now @AmerAcadPeds has released guidance on return to sports for kids after COVID:

Lots of thoughts below

h/t @drjohnm

medscape.com/viewarticle/93…

Physical activity and sports participation can have many health benefits which is recognized in the guidance:

services.aap.org/en/pages/2019-…

They also make a clear statement that COVID19 testing prior to sports participation isn't necessary unless there are symptoms

They recommend measures to reduce potential for spread like practicing in small pods, minimizing travel, cleaning touch points, etc.

They recommend wearing face coverings by all coaches, officials, spectators. Athletes should wear them when arriving and departing. They do recognize that masks may not be possible for some types of vigorous exercise.

They recommend that kids who have very severe infections needing things like ECMO, ventilators, etc, be treated as if they have myocarditis and sit out of exercise for 3-6 months.

My opinion: judicious, symptom limited exercise is probably reasonable earlier. 3-6 months of completely avoiding activity can have long term negative effects on health.

They also suggest that EKG, echo, Holter, ETT and possibly CMR "must have returned to normal, before return to activity"

This is a *a lot* of testing with potential for diagnostic cascades and resultant harm.

Kids w/ moderate disease need to by asymptomatic for 14 days and obtain PCP clearance (including an ECG) before return to exercise.

What is moderate? they aren't clear but they hint that prolonged fever is one. I'm not sure what duration counts as prolonged fever.

Most problematic: kids who have mild or asx infections or even close contact with an infected person need to sit out of exercise for at least 14 days.

Lots of folks have had positive contacts, some are high risk and others are not (duration and type of exposure).

Do all of them need to stop exercise for 2 weeks?

How many of them will not resume exercise at all after such a break?

In this setting, how sensitive is EKG?

There is no mention of troponin. Is this purposeful? Is it recommended against?

What does meeting criteria for myocarditis mean if the patient has no symptoms or signs of it? Especially if the only finding is on CMR?

Most critically, what is the baseline event rate of sudden cardiac death in young adults?

Given CMR diagnosed myocarditis is associated with 2-3X increased risk, what would this imply about the risk in the *subset* of kids with mild cases who also may happen to meet CMR criteria?

Overall I find these recommendations quite problematic.

They carry real risk of creating more harm than benefit.

They are also based on almost no data. No citations, strength of recommendations or level of evidence is provided.

That said, the basic recommendations of wearing masks, distancing, cleaning, etc are good.

They break down when it comes to what to do for asx, mild, and even moderate cases.

Severe cases will definitely have to build their strength back

An important caveat: I'm not a pediatric cardiologist. I'm an adult cardiologist with focus in cardiac imaging and preventive cardiology.

My comments are based on my experience in caring for *adult* heart patients.

Was this helpful?

Important post-script: given obesity, hypertension, diabetes & cardiovascular disease are consistent risk factors for COVID, it seems to me that we should be cautious in advice that could decrease physical activity and increase obesity.