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Asle Hirth
says "no"
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Children are born to be physically active
"The time is definitely too early to recommend pre-participation screening programmes for children"
Asle Hirth
Haukeland University Hospital
Bergen, Norway
Children who are physically active have a better quality of life and improved motor, social, intellectual and emotional development than inactive children. Furthermore, physical activity plays an important role in the primary prevention of atherosclerotic disease. Regular physical activity should therefore be encouraged in all children. A few have conditions that justify restrictions in sports, but this should probably not be applied before the age of 10-12 years.
Although exceptionally rare, sudden unexplained deaths in children participating in sports have been reported. It is a tragedy for all involved and may have major social implications. Could mass screening programs prevent such events?
Pre-participation screening
Studies in the prevention of sudden death in young athletes (defined as under 35 years 
of age) have been conducted. Because the major cause of unexplained death in this population is cardiovascular in origin, the aim of most screening programmes is to discover cardiovascular disease. Questionnaire, physical examination, ECG and echocardiography may be part of the programme. A nationwide Italian programme for pre-participation screening led to a substantial reduction in mortality of young competitive athletes, mostly by preventing sudden death from cardiomyopathy.
Why not screen them all?
Put simply and according to WHO, screening seeks to identify a disease or pre-disease condition in apparently healthy individuals. Mass screening programmes can be applied in conditions that represent an important health problem, where a suitable and safe diagnostic test is available, and an acceptable and established treatment or intervention can be offered. Furthermore, the programme should be cost effective.
None of these criteria would be met if we began cardiovascular screening of children participating in sports. We lack information on the importance of the problem in this population. In adolescents and young adult athletes the reported incidence of sudden cardiac death varies between one in 3500 and one in 300,000. In children we simply do not now.
Questionnaires and physical examination have proved insufficient to detect significant cardiac disease in young athletes. Interpreting a paediatric ECG is challenging and requires experience. Criteria for a pathological ECG with respect to the risk of sudden unexplained death in the young have not been established. The organisation and logistics of such a screening program are overwhelming and the cost-effectiveness is highly debatable.
Why children participating in sport?
The distinction between a child being naturally physically active and a child participating in competitive sport is not clear. Although sudden death is more likely to occur in an athletic than non-athletic young person, this is probably not the case in children. Children tend to put the same effort into their activity, whether it’s in the backyard or on the football field. So there may well be ethical implications if one chooses to include only the competing children in a screening program.
Right now, the time is definitely too early to recommend pre-participation screening programmes for children.
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Erik Jan Meijboom
says "yes"
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All children should undergo pre-participation screening
"The acceptance for this type of pre-participation screening is gradually growing throughout the world."
Erik Jan Meijboom
University Hospital Vaudois
Lausanne, Switzerland
"Death should stay away from young men’s games. Death belongs in musty hospital rooms, sickbeds. It should not impinge its terrible presence on the celebrations of youth, reap its frightful harvest in fields where cheers ring and bands play and banners wave." None of us would disagree with this statement made by the famous American sports journalist Jim Murray. But unfortunately it is not the case. Sudden death in athletes happens, and the incidence of sudden death in those under the age of 35 is higher in athletes than in non-athletes – by 2.5-3 times; 40% of these deaths occur in athletes under the age of 18, and 33% in athletes under 16 years.
The cause of these sudden deaths is cardiovascular in 90% of them, and the vast majority have previously unsuspected structural or arrhythmogenic heart disease. Leading causes include congenital coronary anomalies, hypertrophic cardiomyopathy, arrhythmias and even precocious onset of atherosclerotic coronary artery disease. Some of these diagnoses, like hypertrophic cardiomyopahty and Wolf-Parkinson-White syndrome, cause a mortality which occurs predominantly in the younger age groups.
The stakes are higher
More and younger children are taking part in sports. They do so because they like it, because they aspire to their role models, famous sports heroes, because their parents encourage them and rightfully so. Society attributes a number of virtues to the participation of children in sports, not least because it keeps them healthy and prevents obesity. But just as participation in sports is increasing, so are the stakes. Training has become more seriously and better organised, the level of competition has been raised and the goals are higher.
This is reflected in the sports federations who organise junior championships; just think of FIFA and its World Under-17 Championships and the International Olympic Committee’s first Youth Olympic Games in Singapore in 2010.
To prevent or reduce the number of sudden deaths in sports players the International Olympic Committee and FIFA have both adopted the Lausanne Recommendations of 2004 as an acceptable and relatively simple form of pre-participation screening. These recommendations were based on a number of existing pre-participation protocols. A similar form of screening has already proved effective in Italy, where sudden death mortality has been reduced to levels comparable with - or even better than - those seen in the general population. This pre-participation screening was thought to be applicable to all players spending ten or more hours per week in training, practice or competing in their sport. The acceptance for this type of pre-participation screening is gradually growing throughout the world.
Why should a similar approach not be applicable to the younger generation, whose risks are comparable? What a disaster if the Youth Olympics is marred by the sudden death of a young participant. And for the same reason, why shouldn’t all those young aspiring athletes and their parents benefit from the same protective measures? It would enhance the message that sports participation is healthy, prevents obesity and does indeed possess all the virtues it claims. It would also emphasise that the sudden death of athletes occurs in only a very small group with pre-existing, albeit minor, cardiac anomalies and that screening can reduce this risk to acceptable levels.
The final issue is which youngsters to include. For me it should probably be those who fulfil the same criteria as adult athletes and have at least 10 hours of participation per week. Difficulties will include the expertise to read the junior ECG, and the question of costs and ethics will require further discussion. The Italians have shown that it can be done in a cost effective way.
(All children should undergo pre-participation screening. Debate, Monday 31 August 16:30-18:00, Ankara – Zone 1, FPN 2620-2629)