When patients with bleeding disorders want to play sports or engage in other physical activities, the risks must be balanced with the potential benefits.
The AAP Council on Sports Medicine and Fitness recommends an evaluation for anyone with a bleeding disorder, but the final decision on participation is left to the hematologist, the patient and his or her family.
It is helpful to understand the factors that drive these decisions.
Risk of injury inherent in the sport
The booklet Playing It Safe: Bleeding Disorders, Sports and Exercise (http://bit.ly/2fTkM0g) from the National Hemophilia Foundation includes a five-point scheme that broadly corresponds to the three risk categories (see table) described by Heijnen and colleagues (Haemophilia. 2000;6:537-546) to reflect the level of impact sustained by the participant.
The congruence between impact and risk in hemophilia patients is not absolute since some no-contact sports such as powerlifting or skateboarding fall in a higher risk category than contact/collision sports such as basketball and soccer. In addition, the intensity of sports may vary at different ages.
Type and severity of bleeding disorder
Until the 1970s, sports were discouraged for those with moderate to severe hemophilia or severe (Type 3) Von Willebrand disease (VWD). It was felt that the risk of an intracranial bleed, muscle hematoma or chronic joint bleeds leading to arthropathy outweighed any possible benefit.
Over the next few decades, swimming, golf and table tennis were permitted. A Dutch survey of 239 hemophilia patients in 2000 by Heijnan and colleagues confirmed the psychological impact that being excluded from popular sports such as soccer had on teenage boys with hemophilia.
Due to the myriad potential benefits, including physical, psychological and social well-being, even patients with severe hemophilia now are encouraged to participate in a wide variety of sporting activities, and hemophilia treatment centers have gained greater experience in this area.
Ross and colleagues reported how over a dozen patients with severe hemophilia participated in high-impact sports such as American football (against medical advice) with appropriate monitoring and without event (Pediatrics. 2009;124:1267-1272). A review of 104 patients with hemophilia in Australia (Broderick CR, et al. JAMA. 2012;308:1452-1459) and 48 patients from the Children’s Hospital of Philadelphia (McGee S, et al. Haemophilia. 2015;21:538-542) confirmed that participation in selected sports, with factor prophylaxis as needed, increased neither bleeding nor target joint damage.
The role of new longer-acting factors has not been evaluated in-depth in patients with severe hemophilia who wish to take part in soccer or other moderate-high risk sports, and most hematologists still dose their patients with regular factor to a level of 100% prior to such activity. The patient and family need to keep in mind that even with appropriate prophylaxis, the inherent risks in such sports may be increased in individuals with bleeding disorders.
There is minimal guidance for milder bleeding disorders such as type 1 VWD. However, participation in most sports is encouraged since bleeding in such patients usually is limited to excessive bruising or epistaxis with minimal risk of intracranial bleeding.
Similarly, a survey of 278 pediatric hematologists revealed that 54% of respondents would treat children with immune thrombocytopenia (ITP) to allow sports participation, and over three-quarters of hematologists were comfortable allowing participation in group A activities with platelet counts below 25,000/mm3 (Kumar M, et al. Pediatr Blood Cancer. 2015;62:2223-2225). For Group B and C activities, three-quarters of hematologists were looking for a threshold between 25,000-50,000/mm3 and 50,000-100,000/mm3, respectively, although the link between platelet count in ITP and bleeding during sports activity remains unproven.
Patient age and ability
When counseling about potential risks, it also is important to consider the patient’s age and skill level. Young children with closer adult supervision and less sports-related impact may have reduced risks. In contrast, more competitive athletes and risk-taking adolescents as in teenage soccer players may experience greater sports-related impacts with higher risks. Coaches, athletic trainers, etc. should be made aware of and educated about athletes with a bleeding disorder.
In conclusion, sports participation for children with bleeding disorders not only is permitted, but can be highly desirable when the hematologist, pediatrician and family work together. Knowledge of the underlying disorder and the risks posed by the sport considered can ensure the patient safely enjoys an active lifestyle and the many benefits of sport.
Dr. Kanwar is a member of the AAP Section on Hematology/Oncology. Dr. Canty is a member of the AAP Council on Sports Medicine and Fitness Executive Committee.