This guidance applies to children and adolescents who are participating in and/or returning to physical activity, inclusive of but not limited to, organized sports and physical education class within school. Pediatricians should consider any children or adolescents who participate in any physical activity, organized or not, to fall within the context of this guidance.

This update clarifies CDC guidance for quarantine, isolation and community levels as it relates to sports and provides guidelines for return to physical activity after a COVID-19 diagnosis.

Approximately 35 to 45 million youth 6 to 18 years of age participate in some form of athletics. The COVID-19 pandemic has affected many aspects of the lives of children and families, including youth sport activity. As children present for health supervision visits and preparticipation physical evaluations, parents and athletes likely will ask questions about how best to ensure safety when considering a return to sports participation and physical activity. This guidance is intended for pediatricians to inform families on how to mitigate risk and prevent the spread of SARS-CoV-2, the virus that causes COVID-19, to others within sports and other physical activities. Pediatricians should also refer to their state regulations and guidance associated with return to sports as states are allowing practice and competition to resume at different stages.

Family Considerations

What are the benefits of returning to sports and physical activity for children and adolescents?

Engaging in sports and physical activity with friends has both physical and psychological health benefits for children and adolescents. Participating in sports and physical activity allows youth to improve their cardiovascular health, strength, body composition and overall fitness. Mentally, youth may experience benefits from the increased socialization with friends and coaches as well as from a more structured routine. These psychological and physical benefits can help support their developmental growth. Exercise also has immune system benefits.

The American Academy of Pediatrics (AAP) strongly recommends opportunities for children and adolescents to participate in sports and/or physical fitness activities as long as SARS-CoV-2 transmission mitigation strategies are in place and local authorities approve. A detailed description of transmission mitigation strategies is outlined thoroughly within this document.

What if children’s sports are disrupted or canceled? How can parents support their athletes’ physical and mental well-being?

During the COVID-19 pandemic, opportunities for children and adolescents to be physically active and participate in sports have, at times, been substantially reduced. In addition, millions of children had been learning in a virtual environment, which had increased sedentary time. Obesity prevalence has increased, most significantly for children 5 through 9 years of age, those whose families have lower income, and those who identify as Hispanic and non-Hispanic Black, widening the gap for disparities in these populations.

Children and adolescents who have their sports disrupted should maintain consistent physical activity. This is especially important for athletes who are preparing to return to an organized sport. With a prolonged break from activity, athletes are at significant risk of injury when they return to sports. Apophyseal and physeal injuries are common, as are muscle strains and stress fractures. Significant increases in weight may lead to joint pain and difficulty participating in physical activities. Children and adolescents who are participating in outdoor activity may be at higher risk for heat-related illness if they are not acclimated.

Children and adolescents should be encouraged to begin a gradual return to physical activity if they have not participated in consistent physical activity for more than 1 month. Children and adolescents should start at 25% of their usual volume and intensity of activity and consider every-other-day exercise. An increase of volume of 10% per week is recommended until the desired volume is achieved. Next, intensity of the desired exercise can be increased by 10% per week until the desired intensity is reached. Athletes who participate in sports with an emphasis on running may want to start 8 to 12 weeks prior to the season and perform a beginner running program (such as with a “Couch to 5k” or “None To Run” app) to help guide this gradual increase in impact.

Disruptions in normal routines can be challenging for everyone, especially children and adolescents. Time away from teammates and coaches can be hard on athletes both physically and mentally. Studies have confirmed that the prevalence of depression and/or anxiety is higher in adolescents since the start of the pandemic. All athletes should be monitored for changes in mood, especially those whose sports have been disrupted. Children and adolescents who have been or are unable to participate in milestone events, such as their final high school sports season or a state championship tournament, and those with a prior history of depression and anxiety may be affected more than others.

Should parents and other spectators attend their children’s sports practices and games?

Parents/guardians should follow current CDC recommendations for risk mitigation based on community levels of COVID-19. Attending outdoor events is believed to bear less risk than indoor events, which have less space and poorer ventilation. No one should attend any sports function as a spectator if they are exhibiting signs or symptoms of COVID-19, are in isolation or are currently in quarantine for an exposure. Parents and other spectators with high-risk health conditions should weigh the risk of attending an indoor event or events held outdoors where appropriate physical distancing cannot be maintained. Live streaming or recording of athletic events, when available, may allow people who are unable to attend to participate in viewing events.

What about the sports preparticipation examination and preparing for the season?

All children should have an annual health supervision visit, which ideally incorporates the preparticipation physical evaluation (PPE; also known as the sports physical). Pediatricians should inquire about any known SARS-CoV-2 infections and vaccination/booster status since the last evaluation and should document it within the patient’s medical record. The AAP strongly recommends that all people who are eligible should receive the primary series of the COVID-19 vaccine, receive a booster dose when recommended, and continue to follow transmission mitigation recommendations as described by the CDC.

The PPE History form and Physical Examination form have been revised to incorporate questions regarding COVID-19 history and COVID-19 vaccination status. As part of the PPE, appropriate screening and guidance back to physical activity should be provided as outlined in this document. Please note: Athletes who have a current PPE (per state and local guidance) on file should not need to complete another examination or history form.

Transmission Mitigation

What are the risks of transmission for youth in sports and physical activity?

Pediatricians, policy makers, school administrators and families must consider the mounting evidence regarding COVID-19 in children and adolescents, including the role children and adolescents may play in transmission of the infection.

Because prolonged, close contact with a person infected with SARS-CoV-2 is the main driver of transmission, the sport and physical activity (number of players, spacing and frequency and duration of contact) and setting (indoor versus outdoor, size and ventilation of facility) will influence the risk of infection. SARS-CoV-2 transmission among athletes has been documented in the sports setting, with indoor sports likely bearing the greatest risk, especially wrestling, ice hockey and basketball.

Most transmission associated with outdoor sports has been related to off-field activities, such as sharing meals and during transportation in private vehicles where people were unmasked or partially masked. SARS-CoV-2 infection rates for outdoor sports are likely to reflect local community infection rates. However, with the emergence of new SARS-CoV-2 variants with higher infectivity rates, transmission during outdoor on-field activities is of greater concern.

The AAP recommends that decisions be made on a local level when considering cancellations, delays or limitations in sports. By properly following transmission mitigation strategies of vaccination, use of face masks, and physical distancing, the risk of contracting and transmitting COVID-19 can be decreased.

How do families balance the risk versus benefit of returning to sports for children and adolescents?

Weighing the risk versus benefit of return to sport is driven by the sport and setting, local disease activity and individual circumstances, including underlying health conditions that place the athlete or household contacts at high risk of severe disease should they contract SARS-CoV-2 infection. See the CDC for a list of high-risk conditions. Parents should review the school/league COVID-19 policies and discuss them with their children, so they are aware of the expectations. Risk of contracting COVID-19 can be decreased but not eliminated by athletes, parents, coaches and officials following safety protocols and by getting vaccinated as recommended by the CDC. Ultimately, the decision falls on parents/guardians to decide whether they will allow their children to participate in sports.

Should children have a COVID-19 test before attending sports?

Testing for COVID-19 before participating in sports is not necessary unless an athlete is symptomatic or has been exposed to someone known to be recently infected with SARS-CoV-2. Current testing recommendations can be found in the AAP COVID-19 Testing Guidance. Antibody testing is not currently recommended prior to sports participation.

What modifications/strategies should be considered to reduce risk of transmission during youth sports?

To reduce risk, state and local governments as well as sports governing bodies are recommending modifications to practices, competitions and events. The CDC recommendations for youth sports should be consulted when developing this guidance. Compliance by athletes, parents, spectators, coaches and officials will affect the success of the mitigation strategies. Key modifications include prioritizing noncontact activity, such as conditioning and drills where physical distance can be maintained, and proper use of a face mask as outlined in the next section. In addition, it is important to reinforce appropriate hygiene and respiratory etiquette through signage, parent/athlete education and use of handwashing stations or hand sanitizer. Children and adolescents with any signs or symptoms of SARS-CoV-2 infection should not attend practices or competition. They should consult their pediatrician for testing guidance and notify their coach, athletic trainer and/or school administrator of their signs/symptoms. All children and adolescents who are age eligible should be encouraged to complete the COVID-19 vaccination series as outlined by the CDC.

Maintaining practice groups in consistent pods of small sizes that do not mix youth athletes may help limit team-wide outbreaks of SARS-CoV-2 infection. Small pods allow for easier contact tracing and determining who should be considered a close contact. Minimizing travel to other communities and regions is another reduction strategy. And when travel occurs across county lines, CDC data for community levels should be checked. Frequently touched surfaces on the field, court or play surface (ie, drinking fountains) should be cleaned and disinfected at least daily or between uses as much as possible. Sharing of equipment and use of communal spaces, such as locker rooms, should be reduced. When possible, athletic areas with poor ventilation (ie, weight rooms) or small spaces where distancing cannot be maintained should be avoided, because they bear greater risk for transmission of SARS-CoV-2. Considerations should be made for increased ventilation via opening doors or windows when safe. Athletes should not share food or drink. Participants should be encouraged to bring their own water bottles.

A CDC science brief notes that SARS-CoV-2 transmission remains highest through respiratory droplets carrying infectious virus. With risk of infection through fomite transmission remaining low, transmission mitigation strategies should focus on proper face mask use and physical distancing for athletes, coaches, officials and spectators.

When should face masks be worn?

It is strongly recommended that athletes, coaches, officials and spectators wear a face mask indoors, even if they are vaccinated and boosted, if their county is in the “high” level as defined by the CDC COVID-19 Community level system. A face mask would also be recommended indoors, regardless of community level, in close proximity situations such as in locker rooms, in weight rooms and on transportation, if an athlete or someone on the team or within their home is immunocompromised or considered high risk. If the face mask is removed for a break, the athlete should remain at least 3 feet away from all other people. Coaches and other club/school officials should monitor proper use and encourage all athletes to have a well-fitting face mask in place in accordance with the above guidance and local recommendations.

Make sure your mask fits snugly against the side of your face without gaps, is secured under your chin, and completely covers your nose and mouth. Refer to this CDC guidance on selecting a proper face mask for additional details.

Special considerations may be appropriate when there is an increased risk of heat-related illness. Children younger than 2 years old should not wear a face mask. Younger athletes may find wearing a face mask challenging and may need to be reminded and/or assisted by parents/coaches. People should be reminded not to touch the front of the face mask and remove it from the face touching only the straps whenever possible. Cloth face masks should be washed daily in hot water and not reused until cleaned.

Proper face mask use during indoor sports decreases risk of SARS-CoV-2 transmission, and individuals may choose to wear a face mask at any time to help mitigate risk of infection. If a face mask is indicated for indoor sports activity, it is important to recognize that face masks have been shown to be well tolerated by most people who wear them for exercise. The mask may need to be removed under certain circumstances. Face masks should not be worn during certain situations in competitive cheerleading and gymnastics because of the risk that the mask may get caught on objects and become a choking hazard or accidentally impair vision. For competitive cheer, face mask use should be emphasized when individuals are within 3 feet of each other and risk for mask displacement is low. For gymnastics, the face mask should be removed when athletes are on the apparatus. It should be replaced as soon as the exercise is completed.

During wrestling contact, a face mask could become a choking hazard and is discouraged unless an adult coach or official is closely monitoring for safety purposes. People who swim/dive/participate in water sports should not wear a face mask while they are in the water, because a wet face mask may be more difficult to breathe through. Any face mask that becomes saturated with sweat should be changed immediately. If other sport-specific scenarios arise in which a face mask may obstruct a person’s view or become a choking hazard, league officials should use their discretion to determine whether risk of mask use outweighs risk of SARS-CoV-2 transmission.

Should my athlete/my family travel for sports competitions?

If an athlete/athlete’s family is considering travel for sports competition, recommendations for minimizing risk should be provided. If anyone (athlete and/or family of athlete) has signs/symptoms consistent with COVID-19, is in quarantine for exposure, or is awaiting COVID-19 test results, they should not travel or attend any sports activities. The family should make sure to check if the area of travel requires a period of quarantine upon arrival, or if their home state requires a quarantine upon return home. Mandatory post-travel quarantine periods may affect a person’s ability to attend school in person upon return home, depending on the destination’s test positivity rate. Families should also review competition/tournament COVID-19 safety protocols prior to attending the event.

Some risk reduction strategies people from different households may want to consider are avoiding shared hotel rooms/living space when away from home, shared transportation, and participation in unmasked social activities together away from competition (swimming in hotel pools, eating meals together social time in hotel lobby). A study from the National Football League suggested that sharing meals and/or transportation were shown to be the most common causes of COVID-19 disease transmission. If sharing a car, opening windows when the weather allows to increase ventilation, or wearing a mask may be beneficial.

What if a child/adolescent is identified as a close contact of a person with COVID-19?

All parents/guardians need to report if the youth has been in close contact with anyone who has tested positive for COVID-19. Current CDC guidelines for isolation and quarantine should be followed.

What if a child/adolescent tests positive for COVID-19?

If a child/adolescent tests positive for COVID-19, team officials and the health department should be notified so contact tracing and appropriate quarantining can be performed according to local policy and protocols. All individuals who test positive should follow CDC guidance for isolation. These include the following:

  1. Regardless of vaccine status, the COVID-19-positive individual should isolate at home for a minimum of 5 days.
  2. After a full 5 days have passed from symptom onset or positive test result, the individual may end isolation if asymptomatic or symptoms are improving. Individuals with fever must remain in isolation until a minimum of 24 hours have passed while off fever-reducing medication.
  3. All individuals must mask when around others for a full 10-day period. This includes with all physical activity.

Evaluation for Resumption of Physical Activity/Sports Activity for a Child/Adolescent with COVID-19

What to do if a child or adolescent who is active in sports and/or physical activity tests positive for COVID-19?

All children and adolescents who test positive for COVID-19 should notify their pediatrician. For a child or adolescent who is SARS-CoV-2–positive who is either asymptomatic or mildly symptomatic (<4 days of fever >100.4°F, <1 week of myalgia, chills, and lethargy) an assessment by primary care physician (phone, telemedicine, or in person consultation) is recommended, so appropriate guidance can be given to the family. All individuals should be instructed on proper isolation (duration and restricting exposure to other people within the house). The SARS-CoV-2 infection should be documented within the individual’s medical record.

Recent literature has reported a much lower incidence of myocarditis, 0.5% to 3%, than earlier in the pandemic. However, myocarditis has been documented even in people with COVID-19 who were asymptomatic or had mild infections. The assessment should include appropriate questions about chest pain, shortness of breath out of proportion for upper respiratory tract infection, new-onset palpitations, or syncope. Any child or adolescent who reports these signs/symptoms should have an in-office visit that includes a complete physical examination, and consideration for an EKG should be given prior to clearance to return to physical activity.

Individuals who are asymptomatic or have mild symptoms who complete their 5-day isolation should be fever free off all fever-reducing medication and have improving symptoms for a minimum of 1 day prior to beginning a return to physical activity progression. All athletes and their parents should be provided with guidance to monitor for signs/symptoms concerning for myocarditis as they return to physical activity. This includes monitoring for any onset of chest pain, shortness of breath out of proportion for upper respiratory tract infection, new-onset palpitations, or syncope. These are indications for stopping physical activity and seeking immediate medical care; consultation with a pediatric cardiologist should be encouraged.

For those with moderate symptoms of COVID-19 (≥4 days of fever >100.4°F, ≥1 week of myalgia, chills, or lethargy, or a non-ICU hospital stay and no evidence of multisystem inflammatory syndrome in children [MIS-C]), an evaluation by their primary care physician (PCP) is recommended. People who test positive for SARS-CoV-2 should not exercise until they are cleared by a physician. PCP evaluation is currently recommended after symptom resolution and completion of isolation. The PCP will review the American Heart Association 14-element screening evaluation with special emphasis on cardiac symptoms including chest pain, shortness of breath out of proportion for upper respiratory tract infection, new-onset palpitations, or syncope and perform a complete physical examination and an EKG. If cardiac workup is negative, gradual return to physical activity may be initiated after 10 days have passed from the date of the positive test result, and a minimum of 1 day of symptom resolution (excluding loss of taste/smell) has occurred off fever-reducing medicine. If cardiac sign/symptom screening is positive or EKG is abnormal, referral to a cardiologist is recommended. The cardiologist may consider ordering a troponin test and an echocardiogram at the time of acute infection. Depending on the patient’s symptoms and their duration, additional testing including a Holter monitor, exercise stress testing, or cardiac magnetic resonance imaging (MRI) may be considered

Individuals who have moderate symptoms may not exit their isolation until a minimum of 5 days have passed, symptoms are improving, and they are fever free off all fever-reducing medication for a minimum of 1 day. Physician clearance is required prior to beginning a return to physical activity progression, and a minimum of 1 day of being fever free off fever-reducing medication and improving symptoms is recommended prior to starting a return to physical activity progression. All athletes and their parents should be provided with guidance to monitor for signs/symptoms concerning for myocarditis as they return to physical activity. This includes monitoring for any onset of chest pain, shortness of breath out of proportion for upper respiratory tract infection, new-onset palpitations or syncope. These are indications for stopping physical activity and seeking immediate medical care; consultation with a pediatric cardiologist should be encouraged.

For children and adolescents with severe COVID-19 symptoms (ICU stay and/or intubation) or MIS-C, it is recommended they be restricted from exercise for a minimum of 3 to 6 months and obtain cardiology clearance prior to resuming training or competition. Coordination of follow-up cardiology care should be arranged prior to hospital discharge. Other testing may be ordered based on the child or adolescent’s signs and symptoms.

For children and adolescents with a history of SARS-CoV-2 infection who have already advanced back to physical activity/sports on their own and do not have any abnormal signs/symptoms, no further workup is necessary. It is recommended that these children and adolescents update their pediatrician’s office via a phone call to ensure the history of SARS-CoV-2 infection is added to their medical record.

rtp-algorithm update.jpg

View full chart

After testing positive for SARS-CoV-2, how should children and adolescents return to physical activity and/or sports?

The AAP recommends not returning to sports until children or adolescents have completed isolation, the minimum amount of symptom-free time (as outlined above) has passed, they can perform normal activities of daily living, they display no concerning signs/symptoms, and a physician evaluation has been completed if indicated.

Individuals who exit isolation after 5 days post-symptom onset or positive test should wear a face mask for all activity around other individuals for a total of 10 days from onset of symptoms or positive COVID-19 test, including for all physical activity. If a face mask cannot be worn during their sport (ie, swimming/diving), these individuals may participate in other physical activity as part of their progression until their 10 days has been completed and then can return to their sport without a mask.

All children younger than 12 years with COVID-19 may progress back to sports/physical education classes according to their own tolerance once above steps for isolation and clearance have been completed.

Individuals who are 12 years and older should perform the following progression once isolation is completed and physician clearance has been obtained if indicated:

  • Asymptomatic/mild symptoms: Minimum 1 day symptom free (excluding loss of taste/smell), 2 days of increase in physical activity (ie, one light practice, one normal practice), no games before day 3. A face mask should be worn for ALL physical activity, including games or scrimmages, until 10 full days from positive test or symptom onset have passed.
  • Moderate symptoms: Minimum 1 day symptom free (excluding loss of taste/smell), and a minimum of 4 days of gradual increase in physical activity (one light cardio workout on own, two light practices, one full practice), no games before day 5. A face mask should be worn for ALL physical activity, including games or scrimmages, until 10 full days from positive test or symptom onset have passed.

All children and adolescents and their parents/caregivers should be educated to monitor for chest pain, shortness of breath out of proportion for upper respiratory tract infection, new-onset palpitations, or syncope when returning to exercise. If any of these signs and/or symptoms occur, the AAP recommends immediately stopping exercise and seeing a pediatrician for an in-person assessment, and consideration should be given for pediatric cardiology consultation.

Additional Information

Information for Families from HealthyChildren.org


Interim Guidance Disclaimer:
 The COVID-19 clinical interim guidance provided here has been updated based on current evidence and information available at the time of publishing. Guidance will be regularly reviewed with regards to the evolving nature of the pandemic and emerging evidence. All interim guidance will be presumed to expire on December 31, 2022 unless otherwise specified.

Last Updated

03/24/2022

Source

American Academy of Pediatrics