Editor’s notes: The AAP has updated this guidance since this article was published. Please visit https://bit.ly/3itYJgQ for the latest guidance. AAP interim guidance is based on current evidence and best data at the time of publication. Updates are provided to reflect changes in knowledge about the impact of the disease on children and adolescents.
With some youth sports seasons resuming during the COVID-19 pandemic, pediatricians may find themselves answering questions during preparticipation physical evaluations and health supervision visits about the health and safety of athletes.
AAP “COVID-19 Interim Guidance: Return to Sports” offers guidance for pediatricians to share with athletes on how to mitigate risk and prevent the spread of SARS-CoV-2 to others within the sport, in families and in the community.
Because practice and competition are progressing at different stages across the United States, the guidance also urges pediatricians to refer to state regulations and guidance associated with the return to sports.
“Ultimately, the decision falls on parents/guardians to decide whether they will allow their children to participate in sports,” according to the interim guidance. “Risk can be decreased, but not eliminated, by athletes, parents, coaches, and officials following safety protocols.”
Data to date suggest that children are infected with SARS-CoV-2 less frequently than adults, according to the AAP interim guidance. When they are infected, children typically experience less severe disease.
Pediatricians can refer to the AAP guidance when helping families decide whether to return to sports. Considerations include the type of sport, setting and local disease activity. Individual circumstances also are important, especially for families of athletes who have underlying health conditions or those who live in a household with someone at high risk.
“Because prolonged, close contact with a person infected with SARS-CoV-2 is the main driver of transmission, the sport (number of players, spacing and frequency and duration of contact) and setting (indoor vs. outdoor, size and ventilation of facility) will likely influence the risk of infection,” according the guidance. Pediatricians also can discuss the importance of hand hygiene, sanitizing equipment and avoiding shared equipment.
The interim guidance discourages testing athletes for COVID-19 before participating in sports unless an athlete is symptomatic or has been exposed to someone known to be recently infected with SARS-CoV-2. Antibody testing currently is not recommended.
Athletes who test positive
The interim guidance addresses what to do when an athlete tests positive for SARS-CoV-2. “We believe that all exposures, regardless of symptoms require a minimum two-week resting period, without exercise or competition,” the guidance states.
Any athlete who tests positive for current SARS-CoV-2 infection, even if asymptomatic, should be held out of all practices and games until cleared by a physician. The AAP believes that all exposures regardless of symptoms require a two-week period without exercise or competition. Those with symptoms may require longer restrictions for at least two to four weeks.
Those with severe presentations (e.g., hypotentsion, arrythmias, requiring intubation or extracorporeal membrane oxygenation support) must be treated as though they have myocarditis and restricted from participation for minimum of three to six months, as well as obtain clearance from their pediatrician and/or pediatric medical subspecialist.
Parents should notify team officials if the athlete or any household contact is exhibiting any signs or symptoms of COVID-19 or tests positive, even if asymptomatic. Isolation and quarantine guidance from the Centers for Disease Control and Prevention (see resources) should be followed, in conjunction with the local health department.
Reducing risk
The guidance explains the importance of wearing cloth face coverings (see sidebar). Younger athletes may need to be reminded to wear cloth face coverings or require assistance with cloth face coverings from parents and coaches. It also explains where and how physical distancing can help.
Other risk reduction guidance includes keeping small, consistent pods of athletes; avoiding travel to other communities and regions; and opening windows, using fans and avoiding small, poorly ventilated indoor spaces.
Compliance from coaches, officials, spectators, parents and athletes will impact the success of risk reduction.
Because athletes may not have been physically active due to cancellations and disruptions of sport schedules caused by the pandemic, pediatricians should discuss the importance of a gradual increase in frequency, duration and intensity of exercise.
Pediatricians also should remind families about how disruptions to normal routines affect children and adolescents. The guidance recommends monitoring all athletes for signs and symptoms of depression and anxiety if sports participation is disrupted.
Cloth face coverings: What athletes, coaches, parents should know
Athletes should be reminded not to touch the front of their face covering. Remove face coverings using the straps when possible. Wash cloth face coverings in hot water. Do not reuse them until they have been cleaned.
Face coverings are advised:
- For coaches, officials, volunteers and spectators.
- For all people arriving at and departing from an athletic facility or on the sidelines.
- During non-vigorous exercise when physical distancing is not possible.
Face coverings are not advised:
- In water activities. (Cloth face coverings are recommended at poolside).
- For activities where the cloth face covering could get caught or impair vision.
- If a face covering can cause heat illness.
- For children under 2 years old.
