COVID-19 Interim Guidance: Return to Sports
Jul 30, 2020
This article is from the American Academy of Pediatrics.
Approximately 35 to 45 million youth 6 to 18 years of age participate in some form of athletics. The coronavirus disease 2019 (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. This guidance is intended for pediatricians to inform families on how to mitigate risk and prevent the spread of severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2), the virus that causes COVID-19, to others both within sports and within families and the community. 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.
Re-engaging in sports activity with friends has both physical and psychological health benefits for children and adolescents. Participating in sports 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 the return to a more structured routine. These psychological and physical benefits can help support their developmental growth. Exercise also has immune system benefits.
Data to date suggest that children are infected with SARS-CoV-2 less frequently than adults and, when infected, typically experience less severe disease. Although children have generally not been the source of disease outbreaks, it is possible that children could infect adult coaches, officials, or family members after contracting SARS-CoV-2. Because prolonged, close contact with a person infected with SARS-CoV-2 is the main driver of transmission, the sport (number of players, spacing, and frequency and duration of contact) and setting (indoor versus outdoor, size and ventilation of facility) will likely influence risk of infection. Although it is not likely the main form of transmission, it is possible for SARS-CoV-2 to be transmitted on surfaces; therefore, sports with shared equipment, facilities, or common surfaces may pose additional risk.
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 can be decreased but not eliminated by athletes, parents, coaches, and officials following safety protocols. Ultimately, the decision falls on a parents/guardians to decide whether they will allow their children to participate in sports.
Testing for COVID-19 before participating in sports is discouraged unless an athlete is symptomatic or has been exposed to someone known to be recently infected with SARS-CoV-2. Antibody testing is not currently recommended.
To reduce risk, state and local governments as well as sports governing bodies will be recommending modifications to practices, competitions, and events. The Centers for Disease Control and Prevention (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 reduction strategies. Key modifications that are recommended include prioritizing noncontact activity, such as conditioning and drills where physical distance can be maintained. When physical distancing cannot be maintained, cloth face coverings can reduce risk. In addition, it is important to reinforce appropriate hygiene and respiratory etiquette through the use of signage, parent/athlete education, and use of handwashing stations or hand sanitizer.
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. Minimizing travel to other communities and regions is another reduction strategy. Frequently touched surfaces on the field, court, or play surface (eg, 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 or use of fans when safe. Athletes should not share food or drink. Participants should be encouraged to bring their own water bottles.
Cloth face coverings should be worn by coaches, officials, spectators, and volunteers. All individuals should wear a cloth face covering when arriving to or departing from an athletic facility, because physical distancing is often difficult. All athletes should wear a cloth face mask when on the sidelines, and physical distancing should be followed even in this setting. In some cases, cloth face coverings may cause safety concerns, and adaptations or alternatives should be considered. The World Health Organization does not recommend use of a cloth face covering during vigorous exercise, and the CDC cautions that some people who are engaged in high-intensity activity may not be able to wear a cloth face covering. When nonvigorous exercise is being performed and physical distancing is not possible, a cloth face mask should be worn. Cloth face coverings should not be worn in water activities (eg, swimming, diving) or in activities where they could pose an injury risk as a result of catching on equipment or accidently impairing vision during performance of sport (eg, gymnastics, cheer). Special considerations may be appropriate when there is an increased risk of heat-related illness. Individuals younger than 2 years old should not wear a cloth face covering.
Younger athletes may find wearing a cloth face mask challenging and may need to be reminded and/or assisted by parents/coaches. People should be reminded to not touch the front of the face mask and remove it from the straps whenever possible. Cloth face coverings should be routinely washed daily in hot water and not reused until cleaned.
All parents/guardians need to report if the athlete or any household contact is exhibiting any signs or symptoms of COVID-19 or tests positive for SARS-CoV-2, even if asymptomatic. These individuals should be held out of ALL practices and games until the CDC-recommended isolation or quarantine period has expired. If the test result for SARS-CoV-2 is positive, team officials and the health department should be notified so contact tracing and appropriate quarantining can be performed. The local health department can assist in determining when it is safe for athletes and exposed contacts to return to practice, and guidelines from the CDC should be followed to determine clearance.
Currently, there are insufficient data on COVID-19 and its effects on children and adolescents. We do know that those with severe presentations (hypotension, arrhythmias, requiring intubation or extracorporeal membrane oxygenation [ECMO] support) must be treated as though they have myocarditis and restricted from participation for a duration of 3 to 6 months. It is also recommended that these athletes must be cleared to resume participation by their pediatrician and/or pediatric medical subspecialist. The main question is about what to do with others infected with SARS-CoV-2. The American Academy of Pediatrics (AAP) believes that all exposures, regardless of symptoms, require a minimum 2-week resting period without exercise or competition. Those with symptoms should have at least a 2- to 4-week restriction from exercise and competition. Because of the limited information on COVID-19 and exercise, the AAP strongly encourages that all patients who have had COVID-19 be cleared for participation by their primary care physician. If primary care physicians have any questions regarding their patients’ readiness to return to competition, they should feel free to refer them to the pediatric medical subspecialist who provides care for that particular system.
Parents/guardians should follow current local regulations for social distancing and use of cloth face coverings when considering game attendance. Attending outdoor events may bear less risk than indoor events with less space and ventilation. No one should attend any sports function as a spectator if they are exhibiting signs or symptoms of COVID-19. Parents and other spectators with high-risk health conditions should strongly consider not attending indoor events or events held outdoors where appropriate social distancing cannot be maintained. Live streaming or recording of athletic events, when available, may allow individuals who are unable to attend to participate in viewing events.
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. If prolonged breaks occur in sports, athletes should be encouraged to maintain their fitness with regular physical activity. Consistent activity will help athletes stay in shape for when sports return, and this can help prevent injuries. Exercise can also help serve as a coping mechanism during this stressful time. Routine is important, so consideration should be given to establishing a consistent workout schedule.
Individuals who are unable to participate in milestone events, such as their final high school sports season or a state championship tournament, may be emotionally affected more than other individuals. This loss can also have a significant emotional impact on parents of athletes who may be heavily invested in their children’s sports. All athletes should be monitored for signs and symptoms of depression and anxiety if their sports participation is disrupted. Individuals with a prior history of depression or anxiety may be at greater risk.
All children should have an annual health supervision visit, which ideally incorporates the preparticipation physical evaluation (sports exam). Individuals who have not been physically active prior to the restart of sports may be at higher risk of an overuse injury. A gradual increase in frequency, duration, and intensity of exercise should be encouraged to help avoid injury. With a return to sports in summer months, athletes should also take time to acclimate to exercising in warm weather.