In the adult population, COVID-19 infections appear to affect the heart at a higher rate than other viruses, while in the pediatric population, the virus can cause multi-system inflammatory syndrome (MIS-C) involving the heart. Due to the lack of evidence for cardiac injury from COVID-19 infections in the pediatric population and the low number of pediatric cases, recommendations are made from expert opinion from the sports medicine, infectious disease, and cardiology departments and are subject to change. Algorithm for return to play/activity after COVID-19 infection in pediatric patients.
Selected Podcast
Return to Play in the Pediatric Athlete After COVID-19 Infection
Featured Speakers:
Learn more about Daniel Forsha, MD
Daniel Forsha, MD | Ryan Northup, MD | Amol Purandare, MD | Natalie Stork, MD
Daniel Forsha, MD is a Pediatric Cardiologist.Learn more about Daniel Forsha, MD
Amol Purandare, MD Areas of Interest include Pediatric Infectious Diseases, Antimicrobial Stewardship, Penicillin Allergy Testing.
Learn more about Amol Purandare, MD
Learn more about Amol Purandare, MD
Natalie Stork, MD is a Primary Care Sports Medicine Physician and Nonsurgical Pediatric Orthopedic Physician.
Learn more about Natalie Stork, MD
Learn more about Natalie Stork, MD
Transcription:
Return to Play in the Pediatric Athlete After COVID-19 Infection
Melanie: Welcome to Pediatrics in Practice with Children's Mercy, Kansas City. I'm Melanie Cole. In this panel discussion today, we're examining cardiac screening for the pediatric athlete with suspected or confirmed COVID-19 infection.
One interesting topic we're covering is return-to-play, but with research being limited right now and the need to learn more increasing, guidelines will be determined from expert opinions from the sports medicine, infectious disease and cardiology departments at Children's Mercy Kansas City and are subject to change.
Joining me in this panel are Dr. Natalie Stork, she's a primary care sports medicine physician and non-surgical pediatric orthopedic physician; Dr. Amol Purandare, he's a pediatric infectious disease specialist; Dr. Ryan Northup, he's a pediatric and primary care physician; and Dr. Daniel Forsha, he's a pediatric cardiologist and they're all with Children's Mercy Kansas City.
I'd like to thank you all so much for being a part of this important panel today. And Dr. Purandare, I'd like to start with you. If you would clarify a little bit more about COVID infection and multi-system inflammatory syndrome or MIS-C, how it's affecting kids and what have you seen?
Dr. Amol Purandare: Yeah. Thanks for having us. So I will say, I mean, to start off that, luckily, we are seeing less disease in kids overall. I'd say that kids are less likely than adults to transmit disease and also to become ill as compared to adults. But that being said, when kids end up getting sick, they can have similar symptoms to adults.
Most will start off as either being asymptomatic or having just mild cold symptoms. But we do become concerned when especially if they start moving into moderate or severe types of disease patterns. And in adults, we typically hear about the severe disease being more respiratory in nature. But in kids, there can be a whole range of things that we think about with especially inflammation of the heart being one of the big concerns that can sometimes happen in adults, but we're seeing it also in kids.
And so there's the cold symptoms, the respiratory symptoms and the heart symptoms with active COVID disease, but then we also have to think about four weeks out from either exposure or getting the disease, in kids and in some young adults, we're seeing something called multisystem inflammatory syndrome or MIS-C, which as the name implies is where you're seeing symptoms of kind of varying range in at least two organ groups or organ systems along with fever and then you'll see multiple lab criteria that show full body or systemic inflammation.
And one of the biggest concerns with this is that the heart muscles not only get affected, but you can see some significant inflammation of the vessels leading to the heart or around the heart, which can lead to cardiovascular collapse or vessel aneurysm. And it's really due to these risks that we have to think about long-term consequences and have good followup and care with our pediatricians and cardiologists and sports medicine docs alike.
Melanie: Really important information. So the next question, I'm going to start with Dr. Northup, how are patients presenting to primary care? And then I'd like Dr. Forsha to jump in with some cardiology response.
Dr. Ryan Northup: Yeah, of course. Well, first off, getting back into sports has both physical and psychological benefits for children and teens by improving their overall fitness and mental health. So getting them back on the field or into those activities is essential. Children have been presenting to our office both soon after their 10 to 14-day quarantine to even months later with everything from no symptoms to persistent side effects, such as deconditioning, continued fatigue.
And then a couple of kids who have come in with more concerning symptoms such as chest pain or shortness of breath. The question then arises, so what to do next with the previously routine clearance for sports? And when it comes to those sports, physicals or participation physicals that have previously been routine, we have to now begin including that question, "Since we last saw your child, have they been diagnosed with COVID-19?" Or even those who have been presumed positive after an exposure and accompanying symptoms or not. That has to be an essential question now that we begin including in our practice even again months after the initial infection.
Melanie: Dr. Forsha, what do you have to say about this from the cardiology perspective?
Dr. Daniel Forsha: Thanks. I'm happy to be here. Looking at those that we're seeing in pediatric cardiology, it's a nicely timed question as we are collecting data on about a hundred kids, mostly teenagers who are new referrals to Pediatric Cardiology Clinic, following acute COVID infection that did not require hospitalization and does not meet requirement for MIS-C.
About 40% presented for sports clearance, 50% for persistent and potentially cardiac-related symptoms, such as chest pain, dyspnea on exertion, palpitations, and 30% for an abnormal EKG with a subset having multiple of those indications. Looking at their COVID illness, about half have mild disease and half qualify as moderate disease severity according to the guidelines with only a single asymptomatic patient referred. And hearing from my colleagues at other institutions around the nation, this seems to be pretty typical referral pattern for pediatric cardiology following COVID.
Given the number of COVID cases in our area, I do believe that many kids who meet guidelines for referral to pediatric cardiology, which we'll discuss shortly, aren't making it to us. And talking to primary care providers, it sounds like many families, they're not even bringing these kids into their primary care physician for an evaluation prior to resuming activities despite meeting criteria. That's why we are trying to reach out to the community across multiple platforms to discuss this issue. And we appreciate being given the opportunity to discuss it on your show today.
Melanie: What a great point you're making about referral and what you're seeing around the country and in your community. So Dr. Purandare, after a child tests positive for COVID, what's the recommended evaluation from your point of view?
Dr. Amol Purandare: Yeah, definitely. I mean, I think that a lot of this will depend also on what a child's symptoms are. So, as I mentioned, while most kids are asymptomatic, we also need to be thinking about the kids with a mild case that might be having a low-grade fever, just of 100.4 and maybe some muscle aches, some chills and lethargy versus the kids that have more moderate symptoms, which they might have briefly been hospitalized or had fever that's going on for a little bit longer of a time, maybe a little bit more respiratory concerns, and then the kids that were severe that had ICU hospitalizations or they ended up getting a diagnosis of MIS-C, which might be weeks after the initial exposure.
And so based off of those, they can present a lot of different ways. So I think, you know, asymptomatic and mild might go to your primary care, which Dr. Northup can talk about, and then you might have moderate and severe that might need to be changed. So, I'll pass it on to Dr. Northup to kind of talk about how these kids will show up from a referral base and kind of when they have different symptom types.
Dr. Ryan Northup: Yeah, of course. So the majority of children presenting to clinic have either been positive, but asymptomatic or have been mildly symptomatic with a few days of symptoms, even when it comes to these milder cases though, the recommendation is still that these children should be evaluated by their pediatrician for clearance for return to sports after completing their isolation period.
After this visit another visit for further clearance with your physician is not required unless concerning new pulmonary or cardiac signs and symptoms develop once you resume that physical activity. Overall, AAP recommends that the benchmark be no return to sports until your child can perform their normal activities of daily living without those concerning signs or symptoms.
And so all children younger than 12 years may progress back to sports or physical education classes, according to their own tolerance. Whereas children, adolescents, 12 years and older, a graduated return-to-play protocol can begin once an individual has been cleared by their physician, the minimum amount of time without symptoms being, you know, again, that kind of nine to 10-day period.
And the individual does not exhibit any cardio respiratory symptoms when performing normal activities of daily living. So for the more moderate cases, I'm going to pass it off to Dr. Stork to describe what the workup or evaluation needs to be in that case.
Dr. Natalie Stork: Yes. Thank you, Dr. Northup. I think it is important to reiterate current recommendations. Continue to be based off of expert opinion and honestly have changed and continue to change as we learn more. And so keeping in mind that these may change over the next month to years to come is important.
At this time we recommend that an athlete who has had COVID-19 or presumed COVID-19 characterized by moderate symptoms really should not be exercising until evaluated and cleared by their primary care physician that evaluation can be done by their primary care physician and should really focus on a thorough history and physical exam.
And for this population also recommend that the athlete does have an EKG completed prior to returning to activities. Ideally, this evaluation would occur after their 10-day isolation period and as their symptoms are significantly improved or resolved at that point in time. And if their history, their exam, their EKG are all normal, that athlete may then begin a gradual return to activity as we outlined or we will outline in the little bit here. If their history, their exam or their EKG is abnormal in any way, the patient should be referred to cardiology. And I will let Dr. Forsha discuss a little bit further what patients should be evaluated or how patients should be evaluated that have had a more severe infection or MIS-C presentation.
Dr. Daniel Forsha: Thank you, Dr. Stork. For kids with severe COVID requiring hospitalization in an ICU, or those with MIS-C, they will be referred to pediatric cardiology. Those most severely affected children are known to have more frequent cardiac involvement than those less severe cases. Cardiology will typically consult during their admission and they will be scheduled for outpatient clinic visits as well.
If you were seeing a child that fits these criteria that has not seen cardiology, please refer them for an appointment within the next few weeks prior to their return to play. At the cardiology visit, they will have a history, physical, EKG, echocardiogram, and potentially other cardiac testing. The cardiologist will consider a cardiac MRI and an exercise test depending on the level of initial cardiac involvement in the hospital, as well as ongoing cardiac involvement on more basic screening. This group will have a prolonged period of exercise restrictions, typically three to six months, and cardiology can help with that decision-making.
How we move forward in the future when considering this more advanced testing will depend on what the studies show about the natural history of cardiac involvement in severe disease. As others have mentioned, it's an ever evolving process and we still have much to learn.
Melanie: Well, thank you all for going through those with us. And as Dr. Forsha mentioned, on the description page is the link to these recommendations and they're subject to change. Dr. Northup, you all come from many different specialties and as we're discussing options for available therapies and evaluation for these children, can you please speak briefly about the multidisciplinary approach and why it's ideal for managing these patients?
Dr. Ryan Northup: You know, Melanie, that's a great question. I think the benefit of having so many minds on this challenge of COVID-19 is that there are a lot of people that are dedicated to figuring out exactly all the different aspects of this disease and how it affects our bodies and our children as well. And so, being able to utilize as a general pediatrician, the guidance that is put together by specialists, such as Dr. Stork, Dr. Forsha and Dr. Purandare today really assist us in being able to make those decisions on the ground.
I think we as pediatricians a lot of times will try to minimize referrals, minimize testing done and be a bit more, you know, conservative in terms of our management, but with this type of an issue, there are some, you know, best practice that we've been able to develop at this time. And of course, that may change. It's going to be up to the pediatricians to be able to stay abreast of what those updates are.
And so when it comes to, again, those specialty services that we have on the call today even, it's about trying to ensure that, as a pediatrician, we know what the best practices are and not being afraid at all to pull the trigger on getting somebody else's opinion on this. Calling Dr. Forsha to, you know, just ask the question of, "What about this murmur? Is this the type of kid that needs to see you?"
And I think that Just being able to work together as a team on this issue is going to be essential. But as a pediatrician, just making sure that you're abreast of the data, that's going to be the best case because our families are trusting us to make sure that we're up-to-date on best practices. And I think that as a team, that's how this has to just be approached from the medical perspective.
Melanie: What a great point. So, Dr. Forsha, we're talking about kids with COVID and return-to-play. Why is this important?
Dr. Daniel Forsha: That's an excellent question. Here's why we care. Outside of COVID. We know that viral infections can rarely lead to myocarditis. And even more rarely, kids who return to intense sports following myocarditis can have sudden arrest events on the field of play. Nearly all of these rare cases occur in the 12 to 22-year-old age group with those under 12 years of age appearing protected from this poor outcome. But this is a scary outcome that is creating much of the concern about cardiac involvement following acute COVID.
Here's why I'm mostly reassured. Early data is showing that acute COVID, not including the severe form or MIS-C, appears to lead to myocarditis very rarely in children. In those kids who develop myocarditis from other viruses, we know that the risk of sudden arrest is a very low. And perhaps the most reassuring that despite tens of thousands, perhaps even hundreds of thousands of kids who have tested positive for COVID and have returned to play, there's not a single known case of sudden arrest during sports activity in children or college athletes.
While there's a lot to be reassured by, it does appear that rare myocarditis cases may be seen in children following acute COVID. We've attempted to take all of this into account when creating our return-to-play guidelines, balancing the risks and benefits, and we'll continue to modify them as more data becomes available.
Melanie: Dr. Stork, the next couple of questions here are of great interest to me as an exercise physiologist and to primary care providers listening because, once cleared, how are we getting our athletes back to play? I mean, now there's deconditioning, there's maybe even long-haul complications. As you said, these are subject to change, these are expert opinions and recommendations. So we're learning all the time. So tell us a little bit about what you want whether it's coaches or other providers to know about getting that athlete back in the game.
Dr. Natalie Stork: Melanie, yes, another great question. And in continuing with the theme, answer really is based off of expert opinion at this point in time. Many of the recommendations are really coming from a BJSM article that was published in late summer, early fall. And they described a return-to-play protocol in this article that outlined a five-stage return-to-play really divided over a seven-day period of time.
And I won't go into full detail with the protocol, but we'll summarize kind of the idea behind it. So stage one starts with a short duration of some light aerobic activity. And the athlete is exercising about 15 minutes at about 70% of their maximal heart rate. This stage does not allow for any resistance training or weightlifting, and the athlete will generally complete this stage over a couple of days' time.
If the athlete is able to complete the first stage without any symptoms or without the development of any concerning symptoms, the athlete can then progress to stage two, which is typically about a day that they spend in stage two. Stage two allows for the athlete to increase the time that they are active as well as the intensity. So they are participating in about 30 minutes of aerobic activity at about 80% of their maximal heart rate.
If they do well with stage two, they can progress to stage three, which again increases the time of activities in addition to allowing the athlete to add some light resistance training or weightlifting. And by stage four, the athlete is essentially participating in a fairly normal training pattern, still keeping the aerobic activity around 80% of the maximal heart rate. And then by stage five, the athlete is allowed to return to full competition.
The idea behind this graduated return or gradual return to activity allows the athlete to gradually increase both the dynamic and static load on the cardiovascular system while also monitoring for the development of any more concerning symptoms with this process.
In general, athletes that test positive for COVID-19 will undergo a minimum of 10 days self-isolation, which obviously is in place to minimize transmission while also allowing for monitoring of any development of symptoms. However, that 10 days of self-isolation and often minimal activity will then come at the expense of a component of deconditioning. And so I think this graduated or gradual return to activity allows for a short inherent kind of reconditioning phase as well.
Melanie: Well, that all makes sense, the way you laid that out and it's really very good advice. So Dr. Stork, continuing with you for a second and then onto Dr. Purandare, let's speak about ways to limit transmission of COVID during sport. Now, this is something we've been discussing since last year. Tell us a little bit about what you have seen as far as contact versus non-contact, indoor versus outdoor. Tell us a little bit about some ways, your recommendations to limit that transmission
Dr. Natalie Stork: I think as Dr. Northup had mentioned previously I think everyone can really attest to the benefits of sports for our youth athletes and really the indirect as well as direct effects, including an uptick in mental health concerns we have witnessed as COVID-19 has really changed the way we participate in life, including sports. Early on, youth sports really kind of led the way to some degree for returning to sport, even prior to many of the professional and collegiate leagues returning to activity.
And I'll say too much to my surprise, the spring summer and even fall return-to-sports seemed to proceed better than I would have anticipated had you asked me back in May of 2020. There was an earlier study coming out of Wisconsin looking at youth soccer athletes in the early fall, which demonstrated very little transmission during sports and much of that transmission seemingly pointing back more towards community spread.
With that in mind, however, there's still risk of transmission involved. And more recently, another study coming out of the University of Wisconsin, looking at a nationwide survey of high school athletic directors representing just over about 150,000 athletes. And there appeared to be lower incidence of COVID-19 in outdoor sports as well as non-contact sports, relative to the indoor sports or contact sports.
In addition, there did not appear to be much difference with regard to individual sports versus team sports. They also demonstrated that the use of face masks was associated with a decreased incidence of COVID-19 among indoor sports, and may actually be protective among outdoor sports with prolonged close contact.
So all of that said, I think we continue to go back to the basics that we learned actually quite early on in the pandemic. And that's masks, distancing, good hand hygiene and overall good ventilation continue to be quite effective in mitigating the risk of COVID-19 transmission.
Melanie: So Dr. Purandare, can you expand on this a little bit for us?
Dr. Amol Purandare: Yeah, definitely. I think that, you know, as Dr. Stork mentioned, a lot of kind of the basic factors with hand hygiene and ventilation and masks are all very effective. With the mask wearing, it's going to be really important particularly when we do group sports, but also in isolated sports or whenever we have anyone congregate in one area. The masks are more effective in preventing spread from one person to another, not so much if someone's kind of breathing in your face and you in reception of it. But if everyone is masked up in an area, it helps limit transmission.
And I think a big part of a lot of this is also going to be limiting spectators in sports and doing good contact tracing. If you have symptoms, making sure that you stay away from sports, but it's also that teams are well aware of their players and making sure that there is a good log of when players are symptomatic and when they need to be looked at further for evaluation standpoints.
And then good cleaning processes. So if you're in facilities, making sure your facilities have the adequate materials for cleaning the weight rooms and training rooms and so forth and not necessarily sharing equipment between one another. But by doing all these little steps, each little bit that we do helps with limiting our transmission.
Melanie: I'm so glad you made the point about cleaning equipment because we're all teaching our kids and our athletes about masks and hygiene. I'd like to give you each a final thought, just what you would like other providers to take away from this very important discussion today on cardiac screening for the pediatric athlete with suspected or confirmed COVID-19 infection, really what you'd like them to know from your point of view. Dr. Stork, I'd like to start with you. What would you like to summarize?
Dr. Natalie Stork: So I think important to continue to ask the question as Dr. Northup had mentioned earlier, when you do see patients back in your clinic for various different reasons? Have they had history of COVID-19 or presumed COVID-19 infection? And then I think as mentioned kind of last, the importance of continuing, even as vaccines are coming out, continuing to mask, distance and good hand hygiene is going to be important as we go forward.
Melanie: It certainly is. And Dr. Purandare, I'd like you to come at this particular wrap up from the point of infectious disease and referral and what you'd like community physicians to know about referring to the specialists at Children's Mercy Kansas City.
Dr. Amol Purandare: Yeah. So when it comes to referrals, if there's ever a question about, you know, who's the right person to send a patient to, how can we get connected with a specialist or do we need to see a specialist, all of our providers are always open to talking with community providers. So you can give a call to the infectious diseases group or to discuss kind of just in generally. And we always will update our website as well. And it has some information of who to send patients to from that regard.
And with the follow-ups, if you have any questions of, "Does my patient need to be seen by cardiology?" You know, we can follow the algorithm, but also I think calling and checking with the cardiologists works well, or if there's a question about, “My child still has lingering symptoms, do they need to be seen by infectious diseases?" Again, we'd be happy to discuss that with each provider.
Melanie: Dr. Northup, you're coming from pediatrics and primary care. For the providers in your specialty that have athletes whose parents are concerned, what would you like to tell them to counsel their patients? How would you like them to come at this particular topic and then work to assure and reassure the patients and their family?
Dr. Ryan Northup: Yeah, it's a really good question, Melanie. I think that we as pediatricians or even family practice providers need to begin thinking about the essential nature of asking the COVID-19 history question, really almost as much as the developmental milestones that we ask at every checkup. It's that essential that we're beginning to screen for this in the same way that we screen for social determinants of health and other things as well.
A family might not think to include the fact that the family 11 months ago had COVID-19. And actually it's a really important question for us as we, the pediatricians or family practice providers, are thinking about clearing a child for their sporting event, their physical activity, whatever it is, they're participating in, that it's really important that they get back into, but that we do have that responsibility to begin including that as just a part of our repertoire, as a part of our routines as pediatricians, so that we can then counsel families that, yeah, for the most part, you know, your kid's going to be just fine. And it's more about just asking these questions so that we can take that extra little bit of precaution to ensure that your child is going to be safe moving back into their normal and preferred activities.
Melanie: And Dr. Forsha, last word to you. As a pediatric cardiologist, what would you like other providers to take away from this very important episode we've had today and cardiac screening for the pediatric athlete? How important it is that while rare that we at least acknowledge and listen to these expert opinions and put this all together for us.
Dr. Daniel Forsha: Thanks, Melanie. I agree that we should be largely reassured by the lack of reported poor outcomes while still acknowledging that we need to be vigilant for the rare cases of cardiac involvement. In cardiology, we are happy to see any COVID patient that you are concerned about, but our Children's Mercy guidelines have provided our recommendations on who needs referral prior to return-to-play. That document is linked in the show description. Thank you so much for allowing me to be part of this excellent panel.
Melanie: What great points. I want to thank you all for this riveting and lively discussion on cardiac screening for the pediatric athlete with suspected or confirmed COVID-19 infection. Thank you so much again.
This has been Pediatrics in Practice with Children's Mercy Kansas City. To refer your patient or for more information, please visit childrensmercy.org to get connected with one of our providers. Please also remember to subscribe, rate and review this podcast and all the other Children's Mercy podcasts. I'm Melanie Cole.
Return to Play in the Pediatric Athlete After COVID-19 Infection
Melanie: Welcome to Pediatrics in Practice with Children's Mercy, Kansas City. I'm Melanie Cole. In this panel discussion today, we're examining cardiac screening for the pediatric athlete with suspected or confirmed COVID-19 infection.
One interesting topic we're covering is return-to-play, but with research being limited right now and the need to learn more increasing, guidelines will be determined from expert opinions from the sports medicine, infectious disease and cardiology departments at Children's Mercy Kansas City and are subject to change.
Joining me in this panel are Dr. Natalie Stork, she's a primary care sports medicine physician and non-surgical pediatric orthopedic physician; Dr. Amol Purandare, he's a pediatric infectious disease specialist; Dr. Ryan Northup, he's a pediatric and primary care physician; and Dr. Daniel Forsha, he's a pediatric cardiologist and they're all with Children's Mercy Kansas City.
I'd like to thank you all so much for being a part of this important panel today. And Dr. Purandare, I'd like to start with you. If you would clarify a little bit more about COVID infection and multi-system inflammatory syndrome or MIS-C, how it's affecting kids and what have you seen?
Dr. Amol Purandare: Yeah. Thanks for having us. So I will say, I mean, to start off that, luckily, we are seeing less disease in kids overall. I'd say that kids are less likely than adults to transmit disease and also to become ill as compared to adults. But that being said, when kids end up getting sick, they can have similar symptoms to adults.
Most will start off as either being asymptomatic or having just mild cold symptoms. But we do become concerned when especially if they start moving into moderate or severe types of disease patterns. And in adults, we typically hear about the severe disease being more respiratory in nature. But in kids, there can be a whole range of things that we think about with especially inflammation of the heart being one of the big concerns that can sometimes happen in adults, but we're seeing it also in kids.
And so there's the cold symptoms, the respiratory symptoms and the heart symptoms with active COVID disease, but then we also have to think about four weeks out from either exposure or getting the disease, in kids and in some young adults, we're seeing something called multisystem inflammatory syndrome or MIS-C, which as the name implies is where you're seeing symptoms of kind of varying range in at least two organ groups or organ systems along with fever and then you'll see multiple lab criteria that show full body or systemic inflammation.
And one of the biggest concerns with this is that the heart muscles not only get affected, but you can see some significant inflammation of the vessels leading to the heart or around the heart, which can lead to cardiovascular collapse or vessel aneurysm. And it's really due to these risks that we have to think about long-term consequences and have good followup and care with our pediatricians and cardiologists and sports medicine docs alike.
Melanie: Really important information. So the next question, I'm going to start with Dr. Northup, how are patients presenting to primary care? And then I'd like Dr. Forsha to jump in with some cardiology response.
Dr. Ryan Northup: Yeah, of course. Well, first off, getting back into sports has both physical and psychological benefits for children and teens by improving their overall fitness and mental health. So getting them back on the field or into those activities is essential. Children have been presenting to our office both soon after their 10 to 14-day quarantine to even months later with everything from no symptoms to persistent side effects, such as deconditioning, continued fatigue.
And then a couple of kids who have come in with more concerning symptoms such as chest pain or shortness of breath. The question then arises, so what to do next with the previously routine clearance for sports? And when it comes to those sports, physicals or participation physicals that have previously been routine, we have to now begin including that question, "Since we last saw your child, have they been diagnosed with COVID-19?" Or even those who have been presumed positive after an exposure and accompanying symptoms or not. That has to be an essential question now that we begin including in our practice even again months after the initial infection.
Melanie: Dr. Forsha, what do you have to say about this from the cardiology perspective?
Dr. Daniel Forsha: Thanks. I'm happy to be here. Looking at those that we're seeing in pediatric cardiology, it's a nicely timed question as we are collecting data on about a hundred kids, mostly teenagers who are new referrals to Pediatric Cardiology Clinic, following acute COVID infection that did not require hospitalization and does not meet requirement for MIS-C.
About 40% presented for sports clearance, 50% for persistent and potentially cardiac-related symptoms, such as chest pain, dyspnea on exertion, palpitations, and 30% for an abnormal EKG with a subset having multiple of those indications. Looking at their COVID illness, about half have mild disease and half qualify as moderate disease severity according to the guidelines with only a single asymptomatic patient referred. And hearing from my colleagues at other institutions around the nation, this seems to be pretty typical referral pattern for pediatric cardiology following COVID.
Given the number of COVID cases in our area, I do believe that many kids who meet guidelines for referral to pediatric cardiology, which we'll discuss shortly, aren't making it to us. And talking to primary care providers, it sounds like many families, they're not even bringing these kids into their primary care physician for an evaluation prior to resuming activities despite meeting criteria. That's why we are trying to reach out to the community across multiple platforms to discuss this issue. And we appreciate being given the opportunity to discuss it on your show today.
Melanie: What a great point you're making about referral and what you're seeing around the country and in your community. So Dr. Purandare, after a child tests positive for COVID, what's the recommended evaluation from your point of view?
Dr. Amol Purandare: Yeah, definitely. I mean, I think that a lot of this will depend also on what a child's symptoms are. So, as I mentioned, while most kids are asymptomatic, we also need to be thinking about the kids with a mild case that might be having a low-grade fever, just of 100.4 and maybe some muscle aches, some chills and lethargy versus the kids that have more moderate symptoms, which they might have briefly been hospitalized or had fever that's going on for a little bit longer of a time, maybe a little bit more respiratory concerns, and then the kids that were severe that had ICU hospitalizations or they ended up getting a diagnosis of MIS-C, which might be weeks after the initial exposure.
And so based off of those, they can present a lot of different ways. So I think, you know, asymptomatic and mild might go to your primary care, which Dr. Northup can talk about, and then you might have moderate and severe that might need to be changed. So, I'll pass it on to Dr. Northup to kind of talk about how these kids will show up from a referral base and kind of when they have different symptom types.
Dr. Ryan Northup: Yeah, of course. So the majority of children presenting to clinic have either been positive, but asymptomatic or have been mildly symptomatic with a few days of symptoms, even when it comes to these milder cases though, the recommendation is still that these children should be evaluated by their pediatrician for clearance for return to sports after completing their isolation period.
After this visit another visit for further clearance with your physician is not required unless concerning new pulmonary or cardiac signs and symptoms develop once you resume that physical activity. Overall, AAP recommends that the benchmark be no return to sports until your child can perform their normal activities of daily living without those concerning signs or symptoms.
And so all children younger than 12 years may progress back to sports or physical education classes, according to their own tolerance. Whereas children, adolescents, 12 years and older, a graduated return-to-play protocol can begin once an individual has been cleared by their physician, the minimum amount of time without symptoms being, you know, again, that kind of nine to 10-day period.
And the individual does not exhibit any cardio respiratory symptoms when performing normal activities of daily living. So for the more moderate cases, I'm going to pass it off to Dr. Stork to describe what the workup or evaluation needs to be in that case.
Dr. Natalie Stork: Yes. Thank you, Dr. Northup. I think it is important to reiterate current recommendations. Continue to be based off of expert opinion and honestly have changed and continue to change as we learn more. And so keeping in mind that these may change over the next month to years to come is important.
At this time we recommend that an athlete who has had COVID-19 or presumed COVID-19 characterized by moderate symptoms really should not be exercising until evaluated and cleared by their primary care physician that evaluation can be done by their primary care physician and should really focus on a thorough history and physical exam.
And for this population also recommend that the athlete does have an EKG completed prior to returning to activities. Ideally, this evaluation would occur after their 10-day isolation period and as their symptoms are significantly improved or resolved at that point in time. And if their history, their exam, their EKG are all normal, that athlete may then begin a gradual return to activity as we outlined or we will outline in the little bit here. If their history, their exam or their EKG is abnormal in any way, the patient should be referred to cardiology. And I will let Dr. Forsha discuss a little bit further what patients should be evaluated or how patients should be evaluated that have had a more severe infection or MIS-C presentation.
Dr. Daniel Forsha: Thank you, Dr. Stork. For kids with severe COVID requiring hospitalization in an ICU, or those with MIS-C, they will be referred to pediatric cardiology. Those most severely affected children are known to have more frequent cardiac involvement than those less severe cases. Cardiology will typically consult during their admission and they will be scheduled for outpatient clinic visits as well.
If you were seeing a child that fits these criteria that has not seen cardiology, please refer them for an appointment within the next few weeks prior to their return to play. At the cardiology visit, they will have a history, physical, EKG, echocardiogram, and potentially other cardiac testing. The cardiologist will consider a cardiac MRI and an exercise test depending on the level of initial cardiac involvement in the hospital, as well as ongoing cardiac involvement on more basic screening. This group will have a prolonged period of exercise restrictions, typically three to six months, and cardiology can help with that decision-making.
How we move forward in the future when considering this more advanced testing will depend on what the studies show about the natural history of cardiac involvement in severe disease. As others have mentioned, it's an ever evolving process and we still have much to learn.
Melanie: Well, thank you all for going through those with us. And as Dr. Forsha mentioned, on the description page is the link to these recommendations and they're subject to change. Dr. Northup, you all come from many different specialties and as we're discussing options for available therapies and evaluation for these children, can you please speak briefly about the multidisciplinary approach and why it's ideal for managing these patients?
Dr. Ryan Northup: You know, Melanie, that's a great question. I think the benefit of having so many minds on this challenge of COVID-19 is that there are a lot of people that are dedicated to figuring out exactly all the different aspects of this disease and how it affects our bodies and our children as well. And so, being able to utilize as a general pediatrician, the guidance that is put together by specialists, such as Dr. Stork, Dr. Forsha and Dr. Purandare today really assist us in being able to make those decisions on the ground.
I think we as pediatricians a lot of times will try to minimize referrals, minimize testing done and be a bit more, you know, conservative in terms of our management, but with this type of an issue, there are some, you know, best practice that we've been able to develop at this time. And of course, that may change. It's going to be up to the pediatricians to be able to stay abreast of what those updates are.
And so when it comes to, again, those specialty services that we have on the call today even, it's about trying to ensure that, as a pediatrician, we know what the best practices are and not being afraid at all to pull the trigger on getting somebody else's opinion on this. Calling Dr. Forsha to, you know, just ask the question of, "What about this murmur? Is this the type of kid that needs to see you?"
And I think that Just being able to work together as a team on this issue is going to be essential. But as a pediatrician, just making sure that you're abreast of the data, that's going to be the best case because our families are trusting us to make sure that we're up-to-date on best practices. And I think that as a team, that's how this has to just be approached from the medical perspective.
Melanie: What a great point. So, Dr. Forsha, we're talking about kids with COVID and return-to-play. Why is this important?
Dr. Daniel Forsha: That's an excellent question. Here's why we care. Outside of COVID. We know that viral infections can rarely lead to myocarditis. And even more rarely, kids who return to intense sports following myocarditis can have sudden arrest events on the field of play. Nearly all of these rare cases occur in the 12 to 22-year-old age group with those under 12 years of age appearing protected from this poor outcome. But this is a scary outcome that is creating much of the concern about cardiac involvement following acute COVID.
Here's why I'm mostly reassured. Early data is showing that acute COVID, not including the severe form or MIS-C, appears to lead to myocarditis very rarely in children. In those kids who develop myocarditis from other viruses, we know that the risk of sudden arrest is a very low. And perhaps the most reassuring that despite tens of thousands, perhaps even hundreds of thousands of kids who have tested positive for COVID and have returned to play, there's not a single known case of sudden arrest during sports activity in children or college athletes.
While there's a lot to be reassured by, it does appear that rare myocarditis cases may be seen in children following acute COVID. We've attempted to take all of this into account when creating our return-to-play guidelines, balancing the risks and benefits, and we'll continue to modify them as more data becomes available.
Melanie: Dr. Stork, the next couple of questions here are of great interest to me as an exercise physiologist and to primary care providers listening because, once cleared, how are we getting our athletes back to play? I mean, now there's deconditioning, there's maybe even long-haul complications. As you said, these are subject to change, these are expert opinions and recommendations. So we're learning all the time. So tell us a little bit about what you want whether it's coaches or other providers to know about getting that athlete back in the game.
Dr. Natalie Stork: Melanie, yes, another great question. And in continuing with the theme, answer really is based off of expert opinion at this point in time. Many of the recommendations are really coming from a BJSM article that was published in late summer, early fall. And they described a return-to-play protocol in this article that outlined a five-stage return-to-play really divided over a seven-day period of time.
And I won't go into full detail with the protocol, but we'll summarize kind of the idea behind it. So stage one starts with a short duration of some light aerobic activity. And the athlete is exercising about 15 minutes at about 70% of their maximal heart rate. This stage does not allow for any resistance training or weightlifting, and the athlete will generally complete this stage over a couple of days' time.
If the athlete is able to complete the first stage without any symptoms or without the development of any concerning symptoms, the athlete can then progress to stage two, which is typically about a day that they spend in stage two. Stage two allows for the athlete to increase the time that they are active as well as the intensity. So they are participating in about 30 minutes of aerobic activity at about 80% of their maximal heart rate.
If they do well with stage two, they can progress to stage three, which again increases the time of activities in addition to allowing the athlete to add some light resistance training or weightlifting. And by stage four, the athlete is essentially participating in a fairly normal training pattern, still keeping the aerobic activity around 80% of the maximal heart rate. And then by stage five, the athlete is allowed to return to full competition.
The idea behind this graduated return or gradual return to activity allows the athlete to gradually increase both the dynamic and static load on the cardiovascular system while also monitoring for the development of any more concerning symptoms with this process.
In general, athletes that test positive for COVID-19 will undergo a minimum of 10 days self-isolation, which obviously is in place to minimize transmission while also allowing for monitoring of any development of symptoms. However, that 10 days of self-isolation and often minimal activity will then come at the expense of a component of deconditioning. And so I think this graduated or gradual return to activity allows for a short inherent kind of reconditioning phase as well.
Melanie: Well, that all makes sense, the way you laid that out and it's really very good advice. So Dr. Stork, continuing with you for a second and then onto Dr. Purandare, let's speak about ways to limit transmission of COVID during sport. Now, this is something we've been discussing since last year. Tell us a little bit about what you have seen as far as contact versus non-contact, indoor versus outdoor. Tell us a little bit about some ways, your recommendations to limit that transmission
Dr. Natalie Stork: I think as Dr. Northup had mentioned previously I think everyone can really attest to the benefits of sports for our youth athletes and really the indirect as well as direct effects, including an uptick in mental health concerns we have witnessed as COVID-19 has really changed the way we participate in life, including sports. Early on, youth sports really kind of led the way to some degree for returning to sport, even prior to many of the professional and collegiate leagues returning to activity.
And I'll say too much to my surprise, the spring summer and even fall return-to-sports seemed to proceed better than I would have anticipated had you asked me back in May of 2020. There was an earlier study coming out of Wisconsin looking at youth soccer athletes in the early fall, which demonstrated very little transmission during sports and much of that transmission seemingly pointing back more towards community spread.
With that in mind, however, there's still risk of transmission involved. And more recently, another study coming out of the University of Wisconsin, looking at a nationwide survey of high school athletic directors representing just over about 150,000 athletes. And there appeared to be lower incidence of COVID-19 in outdoor sports as well as non-contact sports, relative to the indoor sports or contact sports.
In addition, there did not appear to be much difference with regard to individual sports versus team sports. They also demonstrated that the use of face masks was associated with a decreased incidence of COVID-19 among indoor sports, and may actually be protective among outdoor sports with prolonged close contact.
So all of that said, I think we continue to go back to the basics that we learned actually quite early on in the pandemic. And that's masks, distancing, good hand hygiene and overall good ventilation continue to be quite effective in mitigating the risk of COVID-19 transmission.
Melanie: So Dr. Purandare, can you expand on this a little bit for us?
Dr. Amol Purandare: Yeah, definitely. I think that, you know, as Dr. Stork mentioned, a lot of kind of the basic factors with hand hygiene and ventilation and masks are all very effective. With the mask wearing, it's going to be really important particularly when we do group sports, but also in isolated sports or whenever we have anyone congregate in one area. The masks are more effective in preventing spread from one person to another, not so much if someone's kind of breathing in your face and you in reception of it. But if everyone is masked up in an area, it helps limit transmission.
And I think a big part of a lot of this is also going to be limiting spectators in sports and doing good contact tracing. If you have symptoms, making sure that you stay away from sports, but it's also that teams are well aware of their players and making sure that there is a good log of when players are symptomatic and when they need to be looked at further for evaluation standpoints.
And then good cleaning processes. So if you're in facilities, making sure your facilities have the adequate materials for cleaning the weight rooms and training rooms and so forth and not necessarily sharing equipment between one another. But by doing all these little steps, each little bit that we do helps with limiting our transmission.
Melanie: I'm so glad you made the point about cleaning equipment because we're all teaching our kids and our athletes about masks and hygiene. I'd like to give you each a final thought, just what you would like other providers to take away from this very important discussion today on cardiac screening for the pediatric athlete with suspected or confirmed COVID-19 infection, really what you'd like them to know from your point of view. Dr. Stork, I'd like to start with you. What would you like to summarize?
Dr. Natalie Stork: So I think important to continue to ask the question as Dr. Northup had mentioned earlier, when you do see patients back in your clinic for various different reasons? Have they had history of COVID-19 or presumed COVID-19 infection? And then I think as mentioned kind of last, the importance of continuing, even as vaccines are coming out, continuing to mask, distance and good hand hygiene is going to be important as we go forward.
Melanie: It certainly is. And Dr. Purandare, I'd like you to come at this particular wrap up from the point of infectious disease and referral and what you'd like community physicians to know about referring to the specialists at Children's Mercy Kansas City.
Dr. Amol Purandare: Yeah. So when it comes to referrals, if there's ever a question about, you know, who's the right person to send a patient to, how can we get connected with a specialist or do we need to see a specialist, all of our providers are always open to talking with community providers. So you can give a call to the infectious diseases group or to discuss kind of just in generally. And we always will update our website as well. And it has some information of who to send patients to from that regard.
And with the follow-ups, if you have any questions of, "Does my patient need to be seen by cardiology?" You know, we can follow the algorithm, but also I think calling and checking with the cardiologists works well, or if there's a question about, “My child still has lingering symptoms, do they need to be seen by infectious diseases?" Again, we'd be happy to discuss that with each provider.
Melanie: Dr. Northup, you're coming from pediatrics and primary care. For the providers in your specialty that have athletes whose parents are concerned, what would you like to tell them to counsel their patients? How would you like them to come at this particular topic and then work to assure and reassure the patients and their family?
Dr. Ryan Northup: Yeah, it's a really good question, Melanie. I think that we as pediatricians or even family practice providers need to begin thinking about the essential nature of asking the COVID-19 history question, really almost as much as the developmental milestones that we ask at every checkup. It's that essential that we're beginning to screen for this in the same way that we screen for social determinants of health and other things as well.
A family might not think to include the fact that the family 11 months ago had COVID-19. And actually it's a really important question for us as we, the pediatricians or family practice providers, are thinking about clearing a child for their sporting event, their physical activity, whatever it is, they're participating in, that it's really important that they get back into, but that we do have that responsibility to begin including that as just a part of our repertoire, as a part of our routines as pediatricians, so that we can then counsel families that, yeah, for the most part, you know, your kid's going to be just fine. And it's more about just asking these questions so that we can take that extra little bit of precaution to ensure that your child is going to be safe moving back into their normal and preferred activities.
Melanie: And Dr. Forsha, last word to you. As a pediatric cardiologist, what would you like other providers to take away from this very important episode we've had today and cardiac screening for the pediatric athlete? How important it is that while rare that we at least acknowledge and listen to these expert opinions and put this all together for us.
Dr. Daniel Forsha: Thanks, Melanie. I agree that we should be largely reassured by the lack of reported poor outcomes while still acknowledging that we need to be vigilant for the rare cases of cardiac involvement. In cardiology, we are happy to see any COVID patient that you are concerned about, but our Children's Mercy guidelines have provided our recommendations on who needs referral prior to return-to-play. That document is linked in the show description. Thank you so much for allowing me to be part of this excellent panel.
Melanie: What great points. I want to thank you all for this riveting and lively discussion on cardiac screening for the pediatric athlete with suspected or confirmed COVID-19 infection. Thank you so much again.
This has been Pediatrics in Practice with Children's Mercy Kansas City. To refer your patient or for more information, please visit childrensmercy.org to get connected with one of our providers. Please also remember to subscribe, rate and review this podcast and all the other Children's Mercy podcasts. I'm Melanie Cole.