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Useful recommendations on managing juvenile and adolescent athletes with COVID-19

Comment by Mark Abela, Sports Cardiology & Exercise Section

Preventive Cardiology
Rehabilitation and Sports Cardiology

The possibility of cardiac sequelae after COVID-19 is now well established. Earlier data reported a very high prevalence of cardiac involvement in infected athletes (up to 15%). (1) Dedicated return-to-play (RTP) protocols have been formulated by several sporting bodies. Data that emerged later in the pandemic however was reassuring, reporting that most athletes with COVID-19 are often asymptomatic or only have mild symptoms. Only a small proportion end up having moderate/severe symptoms in the presence or absence of active cardiac involvement after evaluation.

Striking a balance between safe return to sports practice and encouraging physical activity in previously infected children and adolescents is paramount. The pandemic has already seen a substantial number of young individuals taking on a sedentary lifestyle. An increase in screen time of more than 2h/day on weekdays has already been observed. (2) A drop in weekly minutes spent in moderate-to-vigorous physical activity has also been reported internationally. (3-4) In this latest consensus document issued by the Task Force for Childhood Health of the European Association of Preventive Cardiology, the authors give several recommendations to establish a RTP protocol for juvenile and adolescent athletes. (5)

The authors highlight that young athletes with COVID-19 are often asymptomatic or have mild symptoms. These subjects often have a benign clinical course and frequently return back to competitive sports with no sequelae. A small number of young individuals however succumb to SARS-CoV-2 infection related multisystem inflammatory syndrome (MSI-S), (6) a rare yet severe hyperimmune response in the first 6 weeks after acute infection. MSI-S has an estimated incidence of 2 per 100,000 persons younger than 18 years, 1 in 161 clinically affected individuals. (7) 10-20% of those requiring intensive care because of MSI-S have cardiac involvement (myocarditis, left ventricular dysfunction, pericarditis, malignant arrhythmias, coronary artery aneurysms) with a predominance in male individuals and patients with chronic illnesses. (8) Case mortality ranges between 0.2-2%. (9)

The consensus document recommends a gradual RTP lead by the primary care physician or team doctor in young infected athletes with no or mild symptoms. (5) Echocardiography should not be used routinely in COVID-19 infected athletes who had mild COVID-19. The risk of MSI-S is however a reality. A thorough cardiac evaluation in young athletes with moderate or severe cardiac symptoms is strongly recommended, including those with a drop in athletic performance. A baseline evaluation would include ECG, echocardiography and cardiopulmonary exercise testing. Ambulatory ECG monitoring, cardiac MRI and bloods should be considered in cases where acquired inflammatory disorders (myocarditis or pericarditis) are suspected.

Children infected with SARS-CoV2 are often asymptomatic or have only minor symptoms. Striking a balance between the long-term health benefits of exercise and safe return to competitive sports is paramount. This consensus document is a first official position paper highlighting a pragmatic RTP in juvenile and adolescent athletes. (5)


Mark Abela commented on this article:

5. Cardiac screening prior to return to play after SARS-CoV-2 infection: focus on the child and adolescent athlete: A Clinical Consensus Statement of the Task Force for Childhood Health of the European Association of Preventive Cardiology

Flavio D’Ascenzi, Silvia Castelletti, Paolo Emilio Adami, Elena Cavarretta, María Sanz-de la Garza, Viviana Maestrini, Alessandro Biffi, Paul Kantor, Guido Pieles, Evert Verhagen, Monica Tiberi, Henner Hanssen, Michael Papadakis, Josef Niebauer, Martin Halle

European Journal of Preventive Cardiology, Volume 29, Issue 16, November 2022, Pages 2120–2124,

Other references:

1.    Rajpal S., Tong M.S., Borchers J., Zareba K.M., Obarski T.P., Simonetti O.P., et al. Cardiovascular magnetic resonance findings in competitive athletes recovering from COVID-19 infection. JAMA Cardiol. 2020;6(1):2020–2022
2.    Kovacs VA, Starc G, Brandes M, Kaj M, Blagus R, Leskosek B, Suesse T, Dinya E, Guinhouya BC, Zito V, Rocha PM, Gonzalez BP, Kontsevaya A, Brzezinski M, Bidiugan R, Kiraly A, Csányi T, Okely AD. Physical activity, screen time and the COVID-19 school closures in Europe - An observational study in 10 countries. Eur J Sport Sci 2022;22:1094–1103. 
3.    Dallolio L, Marini S, Masini A, Toselli S, Stagni R, Bisi MC, Gori D, Tessari A, Sansavini A, Lanari M, Bragonzoni L, Ceciliani A. The impact of COVID-19 on physical activity behaviour in Italian primary school children: a comparison before and during pandemic considering gender differences. BMC Public Health 2022;22:52.
4.    Runacres A, Mackintosh KA, Knight RL, Sheeran L, Thatcher R, Shelley J, McNarry MA. Impact of the COVID-19 pandemic on sedentary time and behaviour in children and adults: a systematic review and meta-analysis. Int J Environ Res Public Health 2021; 18:11286.
6.    Alsaied T, Tremoulet AH, Burns JC, Saidi A, Dionne A, Lang SM, Newburger JW, de Ferranti S, Friedman KG. Review of cardiac involvement in multisystem inflammatory syndrome in children. Circulation 2021;143:78–88.
7.    Dufort EM, Koumans EH, Chow EJ, Rosenthal EM, Muse A, Rowlands J, Barranco MA, Maxted AM, Rosenberg ES, Easton D, Udo T, Kumar J, Pulver W, Smith L, Hutton B, Blog D, Zucker H; New York State and Centers for Disease Control and Prevention Multisystem Inflammatory Syndrome in Children Investigation Team. Multisystem inflammatory syndrome in children in New York state. N Engl J Med 2020;383:347–358.
8.    Bailey LC, Razzaghi H, Burrows EK, Bunnell HT, Camacho PEF, Christakis DA, Eckrich D, Kitzmiller M, Lin SM, Magnusen BC, Newland J, Pajor NM, Ranade D, Rao S, Sofela O, Zahner J, Bruno C, Forrest CB. Assessment of 135794 pediatric patients tested for severe acute respiratory syndrome Coronavirus 2 across the United States. JAMA Pediatr 2021;175:176–184.
9.    Lu X, Zhang L, Du H, Zhang J, Li YY, Qu J, Zhang W, Wang Y, Bao S, Li Y, Wu C, Liu H, Liu D, Shao J, Peng X, Yang Y, Liu Z, Xiang Y, Zhang F, Silva RM, Pinkerton KE, Shen K, Xiao H, Xu S, Wong GWK; Chinese Pediatric Novel Coronavirus Study Team. SARS-CoV-2 infection in children. N Engl J Med 2020;382:1663–1665.

Notes to editor

Note: The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.