Children and adolescents with medical conditions present special issues with respect to participation in athletic activities. The pediatrician can play an important role in determining whether a child with a health condition should participate in certain sports by assessing the child's health status, suggesting appropriate equipment or modifications of sports to decrease the risk of injury, and educating the athlete, parent(s) or guardian, and coach regarding the risks of injury as they relate to the child's condition. This report updates a previous policy statement and provides information for pediatricians on sports participation for children and adolescents with medical conditions.

In 2001, the American Academy of Pediatrics published an analysis of medical conditions affecting sports participation.1  This updated report replaces the 2001 policy statement and provides additions and changes to increase the accuracy and completeness of the information.

Health care professionals must determine whether a child with a health condition should participate in a particular sport. One way of determining this is by estimating the relative risk of an acute injury to the athlete by categorizing sports as contact, limited-contact, or noncontact sports (Table 1). This categorization may subdivide contact sports into collision and contact sports; although there may be no clear dividing line between the 2, collision implies greater injury risk. In collision sports (eg, boxing, ice hockey, football, lacrosse, and rodeo), athletes purposely hit or collide with each other or with inanimate objects (including the ground) with great force. In contact sports (eg, basketball and soccer), athletes routinely make contact with each other or with inanimate objects but usually with less force than in collision sports. In limited-contact sports (eg, softball and squash), contact with other athletes or with inanimate objects is infrequent or inadvertent. However, some limited-contact sports (eg, skateboarding) can be as dangerous as collision or contact sports. Even in noncontact sports (eg, power lifting), in which contact is rare and unexpected, serious injuries can occur.

Overuse injuries are related not to contact or collision but to repetitive microtrauma; furthermore, overuse injuries generally are not acute. For these reasons, the categorization of sports in Table 1 insufficiently reflects the relative risks of injury. However, the categorization indicates the comparative likelihood that participation in different sports will result in acute traumatic injuries from blows to the body.

For most chronic health conditions, current evidence supports and encourages the participation of children and adolescents in most athletic activities. However, the medical conditions listed in Table 2 have been assessed to determine whether participation would create an increased risk of injury or affect the child's medical condition adversely. These guidelines can be valuable when a physician examines an athlete who has one of the listed problems. Decisions about sports participation are often complex, and the usefulness of Table 2 is limited by the frequency with which it recommends individual assessment when a “qualified yes” or a “qualified no” appears.

The physician's clinical judgment is essential in the application of these recommendations to a specific patient. This judgment is enhanced by consideration of the available published information on the risks of participation, the risk of acquiring a disease as a result of participation in the sport, and the severity of that disease. Other variables to consider include (1) the advice of knowledgeable experts, (2) the current health status of the athlete, (3) the sport in which the athlete participates, (4) the position played, (5) the level of competition, (6) the maturity of the competitor, (7) the relative size of the athlete (for collision/contact sports), (8) the availability of effective protective equipment that is acceptable to the athlete and/or sport governing body, (9) the availability and efficacy of treatment, (10) whether treatment (eg, rehabilitation of an injury) has been completed, (11) whether the sport can be modified to allow safer participation, and (12) the ability of the athlete's parent(s) or guardian and coach to understand and to accept the risks involved in participation. Potential dangers of associated training activities that lead to repetitive and/or excessive overload also should be considered.

Unfortunately, adequate data on the risks of a particular sport for athletes with medical problems often are limited or lacking, and an estimate of risk becomes a necessary part of the decision-making process. If primary care physicians are uncertain or uncomfortable with the evaluation and/or the decision-making process, they should seek the counsel of a sports medicine specialist or a specialist in the specific area of medical concern. If the physician thinks that restriction from a sport is necessary for a particular patient, then he or she should counsel the athlete and family about safe alternative activities.

Physicians making decisions about sports participation for athletes with cardiovascular disease (Table 2) are strongly encouraged to consider consulting a cardiologist and to review carefully recommendations from the 36th Bethesda Conference.12  The complexities and nuances of cardiovascular disease make it difficult to provide important detailed information in a single table.

An athlete's underlying cardiac pathologic condition and the stress that a sport places on that condition are the 2 primary factors determining the risk of participating in that sport. A strenuous sport can place dynamic (volume) and static (pressure) demands on the cardiovascular system. These demands vary not only with activities of the sport but also with factors such as the associated training activities and the environment, as well as the level of emotional arousal and fitness of the competitors. Figure 1 lists sports according to their dynamic and static demands, as classified by cardiopulmonary experts of the 36th Bethesda Conference.12 

New recommendations on sports participation for athletes with hypertension (Table 2) are available.10,12  The latest blood pressure tables provide the 50th, 90th, 95th, and 99th percentiles based on age, gender, and height.10  The blood pressure reading must be at least 5 mmHg above the 99th percentile before any exclusion from sports is indicated.10  Periodic monitoring of resting (preexercise) blood pressure levels is preferred for readings above the 90th percentile. A more-complete evaluation is performed for sustained blood pressure readings above the 95th percentile.10,12 

In earlier legal decisions, athletes have been permitted to participate in sports despite known medical risks and against medical advice, usually in cases involving missing or nonfunctioning paired organs. In recent years, however, courts have been reluctant to permit athletes to participate in competitive athletics contrary to the team physician's medical recommendation. When an athlete's family seeks to disregard such medical advice against participation, the physician should ask all parents or guardians to sign a written informed consent statement indicating that they have been advised of the potential dangers of participation and that they understand these dangers. The physician should document, with the athlete's signature, that the child or adolescent athlete also understands the risks of participation. To ensure that parents or guardians truly understand the risks and dangers of participation against medical advice, it is recommended that these adults write the statement in their own words and handwriting.5962 

Additional information on the effects of medical problems on the risk of injury during sports participation is available in Care of the Young Athlete by the American Academy of Orthopaedic Surgeons and the American Academy of Pediatrics63  and Preparticipation Physical Evaluation, Third Edition, by the American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine.7  In addition, other American Academy of Pediatrics policy statements include relevant material.6467 

Eric W. Small, MD, Chairperson

Teri M. McCambridge, MD, Chairperson-elect

Holly Benjamin, MD

David T. Bernhardt, MD

Joel S. Brenner, MD, MPH

Charles Cappetta, MD

Joseph A. Congeni, MD

Andrew J. Gregory, MD

Bernard A. Griesemer, MD

Frederick E. Reed, MD

Stephen G. Rice, MD, PhD, MPH

Jorge E. Gomez, MD

Douglas B. Gregory, MD

Paul R. Stricker, MD

Claire Marie Ann LeBlanc, MD

Canadian Paediatric Society

James Raynor, MS, ATC

National Athletic Trainers Association

Michael F. Bergeron, PhD

Anjie Emanuel, MPH

Jeanne Lindros, MPH

FIGURE 1

Classification of sports according to cardiovascular demands (based on combined static and dynamic components).12  This classification is based on peak static and dynamic components achieved during competition. It should be noted, however, that the higher values may be reached during training. The increasing dynamic component is defined in terms of the estimated percentage of maximal oxygen uptake (Max O2) achieved and results in increasing cardiac output. The increasing static component is related to the estimated percentage of maximal voluntary contraction (MVC) reached and results in increasing blood pressure load. Activities with the lowest total cardiovascular demands (cardiac output and blood pressure) are shown in box IA, and those with the highest demands are shown in box IIIC. Boxes IIA and IB depict activities with low/moderate total cardiovascular demands, boxes IIIA, IIB, and IC depict activities with moderate total cardiovascular demands, and boxes IIIB and IIC depict high/moderate total cardiovascular demands. These categories progress diagonally across the graph from lower left to upper right. a Danger of bodily collision. b Increased risk if syncope occurs. c Participation is not recommended by the American Academy of Pediatrics.2 d The American Academy of Pediatrics classifies cricket in the IB box (low static component and moderate dynamic component).58  (Reproduced with permission from Mitchell JH, Haskell W, Snell P, Van Camp SP. 36th Bethesda Conference. Task force 8: classification of sports. J Am Coll Cardiol. 2005;45(8):1364–1367.)

FIGURE 1

Classification of sports according to cardiovascular demands (based on combined static and dynamic components).12  This classification is based on peak static and dynamic components achieved during competition. It should be noted, however, that the higher values may be reached during training. The increasing dynamic component is defined in terms of the estimated percentage of maximal oxygen uptake (Max O2) achieved and results in increasing cardiac output. The increasing static component is related to the estimated percentage of maximal voluntary contraction (MVC) reached and results in increasing blood pressure load. Activities with the lowest total cardiovascular demands (cardiac output and blood pressure) are shown in box IA, and those with the highest demands are shown in box IIIC. Boxes IIA and IB depict activities with low/moderate total cardiovascular demands, boxes IIIA, IIB, and IC depict activities with moderate total cardiovascular demands, and boxes IIIB and IIC depict high/moderate total cardiovascular demands. These categories progress diagonally across the graph from lower left to upper right. a Danger of bodily collision. b Increased risk if syncope occurs. c Participation is not recommended by the American Academy of Pediatrics.2 d The American Academy of Pediatrics classifies cricket in the IB box (low static component and moderate dynamic component).58  (Reproduced with permission from Mitchell JH, Haskell W, Snell P, Van Camp SP. 36th Bethesda Conference. Task force 8: classification of sports. J Am Coll Cardiol. 2005;45(8):1364–1367.)

TABLE 1

Classification of Sports According to Contact

ContactLimited-ContactNoncontact
Basketball Adventure racinga Badminton 
Boxingb Baseball Bodybuildingc 
Cheerleading Bicycling Bowling 
Diving Canoeing or kayaking (white water) Canoeing or kayaking (flat water) 
Extreme sportsd Fencing Crew or rowing 
Field hockey Field events Curling 
Football, tackle     High jump Dance 
Gymnastics     Pole vault Field events 
Ice hockeye Floor hockey     Discus 
Lacrosse Football, flag or touch     Javelin 
Martial artsf Handball     Shot-put 
Rodeo Horseback riding Golf 
Rugby Martial artsf Orienteeringg 
Skiing, downhill Racquetball Power liftingc 
Ski jumping Skating Race walking 
Snowboarding     Ice Riflery 
Soccer     In-line Rope jumping 
Team handball     Roller Running 
Ultimate Frisbee Skiing Sailing 
Water polo     Cross-country Scuba diving 
Wrestling     Water Swimming 
 Skateboarding Table tennis 
 Softball Tennis 
 Squash Track 
 Volleyball  
 Weight lifting  
 Windsurfing or surfing  
ContactLimited-ContactNoncontact
Basketball Adventure racinga Badminton 
Boxingb Baseball Bodybuildingc 
Cheerleading Bicycling Bowling 
Diving Canoeing or kayaking (white water) Canoeing or kayaking (flat water) 
Extreme sportsd Fencing Crew or rowing 
Field hockey Field events Curling 
Football, tackle     High jump Dance 
Gymnastics     Pole vault Field events 
Ice hockeye Floor hockey     Discus 
Lacrosse Football, flag or touch     Javelin 
Martial artsf Handball     Shot-put 
Rodeo Horseback riding Golf 
Rugby Martial artsf Orienteeringg 
Skiing, downhill Racquetball Power liftingc 
Ski jumping Skating Race walking 
Snowboarding     Ice Riflery 
Soccer     In-line Rope jumping 
Team handball     Roller Running 
Ultimate Frisbee Skiing Sailing 
Water polo     Cross-country Scuba diving 
Wrestling     Water Swimming 
 Skateboarding Table tennis 
 Softball Tennis 
 Squash Track 
 Volleyball  
 Weight lifting  
 Windsurfing or surfing  
a

Adventure racing has been added since the previous statement was published and is defined as a combination of 2 or more disciplines, including orienteering and navigation, cross-country running, mountain biking, paddling, and climbing and rope skills.1 

b

The American Academy of Pediatrics opposes participation in boxing for children, adolescents, and young adults.2 

c

The American Academy of Pediatrics recommends limiting bodybuilding and power lifting until the adolescent achieves sexual maturity rating 5 (Tanner stage V).

d

Extreme sports has been added since the previous statement was published.

e

The American Academy of Pediatrics recommends limiting the amount of body checking allowed for hockey players 15 years and younger, to reduce injuries.

f

Martial arts can be subclassified as judo, jujitsu, karate, kung fu, and tae kwon do; some forms are contact sports and others are limited-contact sports.

g

Orienteering is a race (contest) in which competitors use a map and a compass to find their way through unfamiliar territory.

TABLE 2

Medical Conditions and Sports Participation

ConditionMay Participate
Atlantoaxial instability (instability of the joint between cervical vertebrae 1 and 2) Qualified yes 
    Explanation: Athlete (particularly if he or she has Down syndrome or juvenile rheumatoid arthritis with cervical involvement) needs evaluation to assess the risk of spinal cord injury during sports participation, especially when using a trampoline.47   
Bleeding disorder Qualified yes 
    Explanation: Athlete needs evaluation.8,9   
Cardiovascular disease  
    Carditis (inflammation of the heart) No 
        Explanation: Carditis may result in sudden death with exertion.  
    Hypertension (high blood pressure) Qualified yes 
        Explanation: Those with hypertension >5 mm Hg above the 99th percentile for age, gender, and height should avoid heavy weightlifting and power lifting, bodybuilding, and high-static component sports (Fig 1). Those with sustained hypertension (>95th percentile for age, gender, and height) need evaluation.1012  The National High Blood Pressure Education Program Working Group report defined prehypertension and stage 1 and stage 2 hypertension in children and adolescents younger than 18 years of age.10   
    Congenital heart disease (structural heart defects present at birth) Qualified yes 
        Explanation: Consultation with a cardiologist is recommended. Those who have mild forms may participate fully in most cases; those who have moderate or severe forms or who have undergone surgery need evaluation. The 36th Bethesda Conference12  defined mild, moderate, and severe disease for common cardiac lesions.  
    Dysrhythmia (irregular heart rhythm) Qualified yes 
        Long-QT syndrome  
        Malignant ventricular arrhythmias  
        Symptomatic Wolff-Parkinson-White syndrome  
        Advanced heart block  
        Family history of sudden death or previous sudden cardiac event  
        Implantation of a cardioverter-defibrillator  
        Explanation: Consultation with a cardiologist is advised. Those with symptoms (chest pain, syncope, near-syncope, dizziness, shortness of breath, or other symptoms of possible dysrhythmia) or evidence of mitral regurgitation on physical examination need evaluation. All others may participate fully.1315   
    Heart murmur Qualified yes 
        Explanation: If the murmur is innocent (does not indicate heart disease), full participation is permitted. Otherwise, athlete needs evaluation (see structural heart disease, especially hypertrophic cardiomyopathy and mitral valve prolapse).  
    Structural/acquired heart disease  
        Hypertrophic cardiomyopathy Qualified no 
        Coronary artery anomalies Qualified no 
        Arrhythmogenic right ventricular cardiomyopathy Qualified no 
        Acute rheumatic fever with carditis Qualified no 
        Ehlers-Danlos syndrome, vascular form Qualified no 
        Marfan syndrome Qualified yes 
        Mitral valve prolapse Qualified yes 
        Anthracycline use Qualified yes 
        Explanation: Consultation with a cardiologist is recommended. The 36th Bethesda Conference provided detailed recommendations.12,13,1518  Most of these conditions carry a significant risk of sudden cardiac death associated with intense physical exercise. Hypertrophic cardiomyopathy requires thorough and repeated evaluations, because disease may change manifestations during later adolescence.12,13,17  Marfan syndrome with an aortic aneurysm also can cause sudden death during intense physical exercise.18  Athlete who has ever received chemotherapy with anthracyclines may be at increased risk of cardiac problems because of the cardiotoxic effects of the medications, and resistance training in this population should be approached with caution; strength training that avoids isometric contractions may be permitted.19,20  Athlete needs evaluation.  
    Vasculitis/vascular disease Qualified yes 
        Kawasaki disease (coronary artery vasculitis)  
        Pulmonary hypertension  
        Explanation: Consultation with a cardiologist is recommended. Athlete needs individual evaluation to assess risk on the basis of disease activity, pathologic changes, and medical regimen.21   
Cerebral palsy Qualified yes 
    Explanation: Athlete needs evaluation to assess functional capacity to perform sports-specific activity.  
Diabetes mellitus Yes 
    Explanation: All sports can be played with proper attention and appropriate adjustments to diet (particularly carbohydrate intake), blood glucose concentrations, hydration, and insulin therapy. Blood glucose concentrations should be monitored before exercise, every 30 min during continuous exercise, 15 min after completion of exercise, and at bedtime.  
Diarrhea, infectious Qualified no 
    Explanation: Unless symptoms are mild and athlete is fully hydrated, no participation is permitted, because diarrhea may increase risk of dehydration and heat illness (see fever).  
Eating disorders Qualified yes 
    Explanation: Athlete with an eating disorder needs medical and psychiatric assessment before participation.  
Eyes Qualified yes 
    Functionally 1-eyed athlete  
    Loss of an eye  
    Detached retina or family history of retinal detachment at young age  
    High myopia  
    Connective tissue disorder, such as Marfan or Stickler syndrome  
    Previous intraocular eye surgery or serious eye injury  
        Explanation: A functionally 1-eyed athlete is defined as having best-corrected visual acuity worse than 20/40 in the poorer-seeing eye. Such an athlete would suffer significant disability if the better eye were seriously injured, as would an athlete with loss of an eye. Specifically, boxing and full-contact martial arts are not recommended for functionally 1-eyed athletes, because eye protection is impractical and/or not permitted. Some athletes who previously underwent intraocular eye surgery or had a serious eye injury may have increased risk of injury because of weakened eye tissue. Availability of eye guards approved by the American Society for Testing and Materials and other protective equipment may allow participation in most sports, but this must be judged on an individual basis.22,23   
    Conjunctivitis, infectious Qualified no 
        Explanation: Athlete with active infectious conjunctivitis should be excluded from swimming.  
Fever No 
    Explanation: Elevated core temperature may be indicative of a pathologic medical condition (infection or disease) that is often manifest by increased resting metabolism and heart rate. Accordingly, during athlete's usual exercise regimen, the presence of fever can result in greater heat storage, decreased heat tolerance, increased risk of heat illness, increased cardiopulmonary effort, reduced maximal exercise capacity, and increased risk of hypotension because of altered vascular tone and dehydration. On rare occasions, fever may accompany myocarditis or other conditions that may make usual exercise dangerous.  
Gastrointestinal Qualified yes 
    Malabsorption syndromes (celiac disease or cystic fibrosis)  
        Explanation: Athlete needs individual assessment for general malnutrition or specific deficits resulting in coagulation or other defects; with appropriate treatment, these deficits can be treated adequately to permit normal activities.  
    Short-bowel syndrome or other disorders requiring specialized nutritional support, including parenteral or enteral nutrition  
        Explanation: Athlete needs individual assessment for collision, contact, or limited-contact sports. Presence of central or peripheral, indwelling, venous catheter may require special considerations for activities and emergency preparedness for unexpected trauma to the device(s).  
Heat illness, history of Qualified yes 
    Explanation: Because of the likelihood of recurrence, athlete needs individual assessment to determine the presence of predisposing conditions and behaviors and to develop a prevention strategy that includes sufficient acclimatization (to the environment and to exercise intensity and duration), conditioning, hydration, and salt intake, as well as other effective measures to improve heat tolerance and to reduce heat injury risk (such as protective equipment and uniform configurations).24,25   
Hepatitis, infectious (primarily hepatitis C) Yes 
    Explanation: All athletes should receive hepatitis B vaccination before participation. Because of the apparent minimal risk to others, all sports may be played as athlete's state of health allows. For all athletes, skin lesions should be covered properly, and athletic personnel should use universal precautions when handling blood or body fluids with visible blood.26   
HIV infection Yes 
    Explanation: Because of the apparent minimal risk to others, all sports may be played as athlete's state of health allows (especially if viral load is undetectable or very low). For all athletes, skin lesions should be covered properly, and athletic personnel should use universal precautions when handling blood or body fluids with visible blood.26  However, certain sports (such as wrestling and boxing) may create a situation that favors viral transmission (likely bleeding plus skin breaks). If viral load is detectable, then athletes should be advised to avoid such high-contact sports.  
Kidney, absence of one Qualified yes 
    Explanation: Athlete needs individual assessment for contact, collision, and limited-contact sports. Protective equipment may reduce risk of injury to the remaining kidney sufficiently to allow participation in most sports, providing such equipment remains in place during activity.22   
Liver, enlarged Qualified yes 
    Explanation: If the liver is acutely enlarged, then participation should be avoided because of risk of rupture. If the liver is chronically enlarged, then individual assessment is needed before collision, contact, or limited-contact sports are played. Patients with chronic liver disease may have changes in liver function that affect stamina, mental status, coagulation, or nutritional status.  
Malignant neoplasm Qualified yes 
    Explanation: Athlete needs individual assessment.27   
Musculoskeletal disorders Qualified yes 
    Explanation: Athlete needs individual assessment.  
Neurologic disorders  
    History of serious head or spine trauma or abnormality, including craniotomy, epidural bleeding, subdural hematoma, intracerebral hemorrhage, second-impact syndrome, vascular malformation, and neck fracture.4,5,2830  Qualified yes 
        Explanation: Athlete needs individual assessment for collision, contact, or limited-contact sports.  
    History of simple concussion (mild traumatic brain injury), multiple simple concussions, and/or complex concussion Qualified yes 
        Explanation: Athlete needs individual assessment. Research supports a conservative approach to concussion management, including no athletic participation while symptomatic or when deficits in judgment or cognition are detected, followed by graduated return to full activity.2832   
    Myopathies Qualified yes 
        Explanation: Athlete needs individual assessment.  
    Recurrent headaches Yes 
        Explanation: Athlete needs individual assessment.33   
    Recurrent plexopathy (burner or stinger) and cervical cord neuropraxia with persistent defects Qualified yes 
        Explanation: Athlete needs individual assessment for collision, contact, or limited-contact sports; regaining normal strength is important benchmark for return to play.34,35   
    Seizure disorder, well controlled Yes 
        Explanation: Risk of seizure during participation is minimal.36   
    Seizure disorder, poorly controlled Qualified yes 
        Explanation: Athlete needs individual assessment for collision, contact, or limited-contact sports. The following noncontact sports should be avoided: archery, riflery, swimming, weightlifting, power lifting, strength training, and sports involving heights. In these sports, occurrence of a seizure during activity may pose a risk to self or others.36   
Obesity Yes 
    Explanation: Because of the increased risk of heat illness and cardiovascular strain, obese athlete particularly needs careful acclimatization (to the environment and to exercise intensity and duration), sufficient hydration, and potential activity and recovery modifications during competition and training.37   
Organ transplant recipient (and those taking immunosuppressive medications) Qualified yes 
    Explanation: Athlete needs individual assessment for contact, collision, and limited-contact sports. In addition to potential risk of infections, some medications (eg, prednisone) may increase tendency for bruising.  
Ovary, absence of one Yes 
    Explanation: Risk of severe injury to remaining ovary is minimal.  
Pregnancy/postpartum Qualified yes 
    Explanation: Athlete needs individual assessment. As pregnancy progresses, modifications to usual exercise routines will become necessary. Activities with high risk of falling or abdominal trauma should be avoided. Scuba diving and activities posing risk of altitude sickness should also be avoided during pregnancy. After the birth, physiological and morphologic changes of pregnancy take 4 to 6 weeks to return to baseline.38,39   
Respiratory conditions  
    Pulmonary compromise, including cystic fibrosis Qualified yes 
        Explanation: Athlete needs individual assessment but, generally, all sports may be played if oxygenation remains satisfactory during graded exercise test. Athletes with cystic fibrosis need acclimatization and good hydration to reduce risk of heat illness.  
    Asthma Yes 
        Explanation: With proper medication and education, only athletes with severe asthma need to modify their participation. For those using inhalers, recommend having a written action plan and using a peak flowmeter daily.4043  Athletes with asthma may encounter risks when scuba diving.  
    Acute upper respiratory infection Qualified yes 
        Explanation: Upper respiratory obstruction may affect pulmonary function. Athlete needs individual assessment for all except mild disease (see fever).  
Rheumatologic diseases Qualified yes 
    Juvenile rheumatoid arthritis  
        Explanation: Athletes with systemic or polyarticular juvenile rheumatoid arthritis and history of cervical spine involvement need radiographs of vertebrae C1 and C2 to assess risk of spinal cord injury. Athletes with systemic or HLA-B27-associated arthritis require cardiovascular assessment for possible cardiac complications during exercise. For those with micrognathia (open bite and exposed teeth), mouth guards are helpful. If uveitis is present, risk of eye damage from trauma is increased; ophthalmologic assessment is recommended. If visually impaired, guidelines for functionally 1-eyed athletes should be followed.44   
    Juvenile dermatomyositis, idiopathic myositis  
    Systemic lupus erythematosis  
    Raynaud phenomenon  
        Explanation: Athlete with juvenile dermatomyositis or systemic lupus erythematosis with cardiac involvement requires cardiology assessment before participation. Athletes receiving systemic corticosteroid therapy are at higher risk of osteoporotic fractures and avascular necrosis, which should be assessed before clearance; those receiving immunosuppressive medications are at higher risk of serious infection. Sports activities should be avoided when myositis is active. Rhabdomyolysis during intensive exercise may cause renal injury in athletes with idiopathic myositis and other myopathies. Because of photosensitivity with juvenile dermatomyositis and systemic lupus erythematosis, sun protection is necessary during outdoor activities. With Raynaud phenomenon, exposure to the cold presents risk to hands and feet.4548   
Sickle cell disease Qualified yes 
    Explanation: Athlete needs individual assessment. In general, if illness status permits, all sports may be played; however, any sport or activity that entails overexertion, overheating, dehydration, or chilling should be avoided. Participation at high altitude, especially when not acclimatized, also poses risk of sickle cell crisis.  
Sickle cell trait Yes 
    Explanation: Athletes with sickle cell trait generally do not have increased risk of sudden death or other medical problems during athletic participation under normal environmental conditions. However, when high exertional activity is performed under extreme conditions of heat and humidity or increased altitude, such catastrophic complications have occurred rarely.8,4952  Athletes with sickle cell trait, like all athletes, should be progressively acclimatized to the environment and to the intensity and duration of activities and should be sufficiently hydrated to reduce the risk of exertional heat illness and/or rhabdomyolysis.25  According to National Institutes of Health management guidelines, sickle cell trait is not a contraindication to participation in competitive athletics, and there is no requirement for screening before participation.53  More research is needed to assess fully potential risks and benefits of screening athletes for sickle cell trait.  
Skin infections, including herpes simplex, molluscum contagiosum, verrucae (warts), staphylococcal and streptococcal infections (furuncles [boils], carbuncles, impetigo, methicillin-resistant Staphylococcus aureus [cellulitis and/or abscesses]), scabies, and tinea Qualified yes 
    Explanation: During contagious periods, participation in gymnastics or cheerleading with mats, martial arts, wrestling, or other collision, contact, or limited-contact sports is not allowed.5457   
Spleen, enlarged Qualified yes 
    Explanation: If the spleen is acutely enlarged, then participation should be avoided because of risk of rupture. If the spleen is chronically enlarged, then individual assessment is needed before collision, contact, or limited-contact sports are played.  
Testicle, undescended or absence of one Yes 
    Explanation: Certain sports may require a protective cup.22   
ConditionMay Participate
Atlantoaxial instability (instability of the joint between cervical vertebrae 1 and 2) Qualified yes 
    Explanation: Athlete (particularly if he or she has Down syndrome or juvenile rheumatoid arthritis with cervical involvement) needs evaluation to assess the risk of spinal cord injury during sports participation, especially when using a trampoline.47   
Bleeding disorder Qualified yes 
    Explanation: Athlete needs evaluation.8,9   
Cardiovascular disease  
    Carditis (inflammation of the heart) No 
        Explanation: Carditis may result in sudden death with exertion.  
    Hypertension (high blood pressure) Qualified yes 
        Explanation: Those with hypertension >5 mm Hg above the 99th percentile for age, gender, and height should avoid heavy weightlifting and power lifting, bodybuilding, and high-static component sports (Fig 1). Those with sustained hypertension (>95th percentile for age, gender, and height) need evaluation.1012  The National High Blood Pressure Education Program Working Group report defined prehypertension and stage 1 and stage 2 hypertension in children and adolescents younger than 18 years of age.10   
    Congenital heart disease (structural heart defects present at birth) Qualified yes 
        Explanation: Consultation with a cardiologist is recommended. Those who have mild forms may participate fully in most cases; those who have moderate or severe forms or who have undergone surgery need evaluation. The 36th Bethesda Conference12  defined mild, moderate, and severe disease for common cardiac lesions.  
    Dysrhythmia (irregular heart rhythm) Qualified yes 
        Long-QT syndrome  
        Malignant ventricular arrhythmias  
        Symptomatic Wolff-Parkinson-White syndrome  
        Advanced heart block  
        Family history of sudden death or previous sudden cardiac event  
        Implantation of a cardioverter-defibrillator  
        Explanation: Consultation with a cardiologist is advised. Those with symptoms (chest pain, syncope, near-syncope, dizziness, shortness of breath, or other symptoms of possible dysrhythmia) or evidence of mitral regurgitation on physical examination need evaluation. All others may participate fully.1315   
    Heart murmur Qualified yes 
        Explanation: If the murmur is innocent (does not indicate heart disease), full participation is permitted. Otherwise, athlete needs evaluation (see structural heart disease, especially hypertrophic cardiomyopathy and mitral valve prolapse).  
    Structural/acquired heart disease  
        Hypertrophic cardiomyopathy Qualified no 
        Coronary artery anomalies Qualified no 
        Arrhythmogenic right ventricular cardiomyopathy Qualified no 
        Acute rheumatic fever with carditis Qualified no 
        Ehlers-Danlos syndrome, vascular form Qualified no 
        Marfan syndrome Qualified yes 
        Mitral valve prolapse Qualified yes 
        Anthracycline use Qualified yes 
        Explanation: Consultation with a cardiologist is recommended. The 36th Bethesda Conference provided detailed recommendations.12,13,1518  Most of these conditions carry a significant risk of sudden cardiac death associated with intense physical exercise. Hypertrophic cardiomyopathy requires thorough and repeated evaluations, because disease may change manifestations during later adolescence.12,13,17  Marfan syndrome with an aortic aneurysm also can cause sudden death during intense physical exercise.18  Athlete who has ever received chemotherapy with anthracyclines may be at increased risk of cardiac problems because of the cardiotoxic effects of the medications, and resistance training in this population should be approached with caution; strength training that avoids isometric contractions may be permitted.19,20  Athlete needs evaluation.  
    Vasculitis/vascular disease Qualified yes 
        Kawasaki disease (coronary artery vasculitis)  
        Pulmonary hypertension  
        Explanation: Consultation with a cardiologist is recommended. Athlete needs individual evaluation to assess risk on the basis of disease activity, pathologic changes, and medical regimen.21   
Cerebral palsy Qualified yes 
    Explanation: Athlete needs evaluation to assess functional capacity to perform sports-specific activity.  
Diabetes mellitus Yes 
    Explanation: All sports can be played with proper attention and appropriate adjustments to diet (particularly carbohydrate intake), blood glucose concentrations, hydration, and insulin therapy. Blood glucose concentrations should be monitored before exercise, every 30 min during continuous exercise, 15 min after completion of exercise, and at bedtime.  
Diarrhea, infectious Qualified no 
    Explanation: Unless symptoms are mild and athlete is fully hydrated, no participation is permitted, because diarrhea may increase risk of dehydration and heat illness (see fever).  
Eating disorders Qualified yes 
    Explanation: Athlete with an eating disorder needs medical and psychiatric assessment before participation.  
Eyes Qualified yes 
    Functionally 1-eyed athlete  
    Loss of an eye  
    Detached retina or family history of retinal detachment at young age  
    High myopia  
    Connective tissue disorder, such as Marfan or Stickler syndrome  
    Previous intraocular eye surgery or serious eye injury  
        Explanation: A functionally 1-eyed athlete is defined as having best-corrected visual acuity worse than 20/40 in the poorer-seeing eye. Such an athlete would suffer significant disability if the better eye were seriously injured, as would an athlete with loss of an eye. Specifically, boxing and full-contact martial arts are not recommended for functionally 1-eyed athletes, because eye protection is impractical and/or not permitted. Some athletes who previously underwent intraocular eye surgery or had a serious eye injury may have increased risk of injury because of weakened eye tissue. Availability of eye guards approved by the American Society for Testing and Materials and other protective equipment may allow participation in most sports, but this must be judged on an individual basis.22,23   
    Conjunctivitis, infectious Qualified no 
        Explanation: Athlete with active infectious conjunctivitis should be excluded from swimming.  
Fever No 
    Explanation: Elevated core temperature may be indicative of a pathologic medical condition (infection or disease) that is often manifest by increased resting metabolism and heart rate. Accordingly, during athlete's usual exercise regimen, the presence of fever can result in greater heat storage, decreased heat tolerance, increased risk of heat illness, increased cardiopulmonary effort, reduced maximal exercise capacity, and increased risk of hypotension because of altered vascular tone and dehydration. On rare occasions, fever may accompany myocarditis or other conditions that may make usual exercise dangerous.  
Gastrointestinal Qualified yes 
    Malabsorption syndromes (celiac disease or cystic fibrosis)  
        Explanation: Athlete needs individual assessment for general malnutrition or specific deficits resulting in coagulation or other defects; with appropriate treatment, these deficits can be treated adequately to permit normal activities.  
    Short-bowel syndrome or other disorders requiring specialized nutritional support, including parenteral or enteral nutrition  
        Explanation: Athlete needs individual assessment for collision, contact, or limited-contact sports. Presence of central or peripheral, indwelling, venous catheter may require special considerations for activities and emergency preparedness for unexpected trauma to the device(s).  
Heat illness, history of Qualified yes 
    Explanation: Because of the likelihood of recurrence, athlete needs individual assessment to determine the presence of predisposing conditions and behaviors and to develop a prevention strategy that includes sufficient acclimatization (to the environment and to exercise intensity and duration), conditioning, hydration, and salt intake, as well as other effective measures to improve heat tolerance and to reduce heat injury risk (such as protective equipment and uniform configurations).24,25   
Hepatitis, infectious (primarily hepatitis C) Yes 
    Explanation: All athletes should receive hepatitis B vaccination before participation. Because of the apparent minimal risk to others, all sports may be played as athlete's state of health allows. For all athletes, skin lesions should be covered properly, and athletic personnel should use universal precautions when handling blood or body fluids with visible blood.26   
HIV infection Yes 
    Explanation: Because of the apparent minimal risk to others, all sports may be played as athlete's state of health allows (especially if viral load is undetectable or very low). For all athletes, skin lesions should be covered properly, and athletic personnel should use universal precautions when handling blood or body fluids with visible blood.26  However, certain sports (such as wrestling and boxing) may create a situation that favors viral transmission (likely bleeding plus skin breaks). If viral load is detectable, then athletes should be advised to avoid such high-contact sports.  
Kidney, absence of one Qualified yes 
    Explanation: Athlete needs individual assessment for contact, collision, and limited-contact sports. Protective equipment may reduce risk of injury to the remaining kidney sufficiently to allow participation in most sports, providing such equipment remains in place during activity.22   
Liver, enlarged Qualified yes 
    Explanation: If the liver is acutely enlarged, then participation should be avoided because of risk of rupture. If the liver is chronically enlarged, then individual assessment is needed before collision, contact, or limited-contact sports are played. Patients with chronic liver disease may have changes in liver function that affect stamina, mental status, coagulation, or nutritional status.  
Malignant neoplasm Qualified yes 
    Explanation: Athlete needs individual assessment.27   
Musculoskeletal disorders Qualified yes 
    Explanation: Athlete needs individual assessment.  
Neurologic disorders  
    History of serious head or spine trauma or abnormality, including craniotomy, epidural bleeding, subdural hematoma, intracerebral hemorrhage, second-impact syndrome, vascular malformation, and neck fracture.4,5,2830  Qualified yes 
        Explanation: Athlete needs individual assessment for collision, contact, or limited-contact sports.  
    History of simple concussion (mild traumatic brain injury), multiple simple concussions, and/or complex concussion Qualified yes 
        Explanation: Athlete needs individual assessment. Research supports a conservative approach to concussion management, including no athletic participation while symptomatic or when deficits in judgment or cognition are detected, followed by graduated return to full activity.2832   
    Myopathies Qualified yes 
        Explanation: Athlete needs individual assessment.  
    Recurrent headaches Yes 
        Explanation: Athlete needs individual assessment.33   
    Recurrent plexopathy (burner or stinger) and cervical cord neuropraxia with persistent defects Qualified yes 
        Explanation: Athlete needs individual assessment for collision, contact, or limited-contact sports; regaining normal strength is important benchmark for return to play.34,35   
    Seizure disorder, well controlled Yes 
        Explanation: Risk of seizure during participation is minimal.36   
    Seizure disorder, poorly controlled Qualified yes 
        Explanation: Athlete needs individual assessment for collision, contact, or limited-contact sports. The following noncontact sports should be avoided: archery, riflery, swimming, weightlifting, power lifting, strength training, and sports involving heights. In these sports, occurrence of a seizure during activity may pose a risk to self or others.36   
Obesity Yes 
    Explanation: Because of the increased risk of heat illness and cardiovascular strain, obese athlete particularly needs careful acclimatization (to the environment and to exercise intensity and duration), sufficient hydration, and potential activity and recovery modifications during competition and training.37   
Organ transplant recipient (and those taking immunosuppressive medications) Qualified yes 
    Explanation: Athlete needs individual assessment for contact, collision, and limited-contact sports. In addition to potential risk of infections, some medications (eg, prednisone) may increase tendency for bruising.  
Ovary, absence of one Yes 
    Explanation: Risk of severe injury to remaining ovary is minimal.  
Pregnancy/postpartum Qualified yes 
    Explanation: Athlete needs individual assessment. As pregnancy progresses, modifications to usual exercise routines will become necessary. Activities with high risk of falling or abdominal trauma should be avoided. Scuba diving and activities posing risk of altitude sickness should also be avoided during pregnancy. After the birth, physiological and morphologic changes of pregnancy take 4 to 6 weeks to return to baseline.38,39   
Respiratory conditions  
    Pulmonary compromise, including cystic fibrosis Qualified yes 
        Explanation: Athlete needs individual assessment but, generally, all sports may be played if oxygenation remains satisfactory during graded exercise test. Athletes with cystic fibrosis need acclimatization and good hydration to reduce risk of heat illness.  
    Asthma Yes 
        Explanation: With proper medication and education, only athletes with severe asthma need to modify their participation. For those using inhalers, recommend having a written action plan and using a peak flowmeter daily.4043  Athletes with asthma may encounter risks when scuba diving.  
    Acute upper respiratory infection Qualified yes 
        Explanation: Upper respiratory obstruction may affect pulmonary function. Athlete needs individual assessment for all except mild disease (see fever).  
Rheumatologic diseases Qualified yes 
    Juvenile rheumatoid arthritis  
        Explanation: Athletes with systemic or polyarticular juvenile rheumatoid arthritis and history of cervical spine involvement need radiographs of vertebrae C1 and C2 to assess risk of spinal cord injury. Athletes with systemic or HLA-B27-associated arthritis require cardiovascular assessment for possible cardiac complications during exercise. For those with micrognathia (open bite and exposed teeth), mouth guards are helpful. If uveitis is present, risk of eye damage from trauma is increased; ophthalmologic assessment is recommended. If visually impaired, guidelines for functionally 1-eyed athletes should be followed.44   
    Juvenile dermatomyositis, idiopathic myositis  
    Systemic lupus erythematosis  
    Raynaud phenomenon  
        Explanation: Athlete with juvenile dermatomyositis or systemic lupus erythematosis with cardiac involvement requires cardiology assessment before participation. Athletes receiving systemic corticosteroid therapy are at higher risk of osteoporotic fractures and avascular necrosis, which should be assessed before clearance; those receiving immunosuppressive medications are at higher risk of serious infection. Sports activities should be avoided when myositis is active. Rhabdomyolysis during intensive exercise may cause renal injury in athletes with idiopathic myositis and other myopathies. Because of photosensitivity with juvenile dermatomyositis and systemic lupus erythematosis, sun protection is necessary during outdoor activities. With Raynaud phenomenon, exposure to the cold presents risk to hands and feet.4548   
Sickle cell disease Qualified yes 
    Explanation: Athlete needs individual assessment. In general, if illness status permits, all sports may be played; however, any sport or activity that entails overexertion, overheating, dehydration, or chilling should be avoided. Participation at high altitude, especially when not acclimatized, also poses risk of sickle cell crisis.  
Sickle cell trait Yes 
    Explanation: Athletes with sickle cell trait generally do not have increased risk of sudden death or other medical problems during athletic participation under normal environmental conditions. However, when high exertional activity is performed under extreme conditions of heat and humidity or increased altitude, such catastrophic complications have occurred rarely.8,4952  Athletes with sickle cell trait, like all athletes, should be progressively acclimatized to the environment and to the intensity and duration of activities and should be sufficiently hydrated to reduce the risk of exertional heat illness and/or rhabdomyolysis.25  According to National Institutes of Health management guidelines, sickle cell trait is not a contraindication to participation in competitive athletics, and there is no requirement for screening before participation.53  More research is needed to assess fully potential risks and benefits of screening athletes for sickle cell trait.  
Skin infections, including herpes simplex, molluscum contagiosum, verrucae (warts), staphylococcal and streptococcal infections (furuncles [boils], carbuncles, impetigo, methicillin-resistant Staphylococcus aureus [cellulitis and/or abscesses]), scabies, and tinea Qualified yes 
    Explanation: During contagious periods, participation in gymnastics or cheerleading with mats, martial arts, wrestling, or other collision, contact, or limited-contact sports is not allowed.5457   
Spleen, enlarged Qualified yes 
    Explanation: If the spleen is acutely enlarged, then participation should be avoided because of risk of rupture. If the spleen is chronically enlarged, then individual assessment is needed before collision, contact, or limited-contact sports are played.  
Testicle, undescended or absence of one Yes 
    Explanation: Certain sports may require a protective cup.22   

This table is designed for use by medical and nonmedical personnel. "Needs evaluation" means that a physician with appropriate knowledge and experience should assess the safety of a given sport for an athlete with the listed medical condition. Unless otherwise noted, this need for special consideration is because of variability in the severity of the disease, the risk of injury for the specific sports listed in Table 1, or both.

All clinical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaf.rmed, revised, or retired at or before that time.

The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

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