2020 Guideline Changes: Return-to-Play, Rooming In

William T. Basco, Jr, MD, MS


December 18, 2020

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COVID-19 is now so widespread that it has triggered a need to update guidelines for care of non-COVID conditions in children who have been infected.

Here are two that you need to know about.

When Can Infected Student Athletes Return to Play?

Now that so many community members have caught and recovered from COVID-19, pediatricians are being faced with return-to-play (RTP) questions among high school competitive athletes. The American College of Cardiology's Sports and Exercise Cardiology Section has proposed new guidelines.

The document emphasizes that, like many COVID-19 recommendations, these are certainly subject to change as more data become available. In fact, that is what this guidance represents — a second iteration of recommendations issued in the spring by some of the same authors who outlined a risk-stratified approach to testing and RTP.

There's a lot of excellent detail in the report, but I'll focus on some of the everyday useful take-home points:

Cardiac testing. Tests that may be considered for athletes who experience COVID-19 include ECG, echocardiograms, high-sensitivity testing for troponin I levels, and cardiac MRI.

Some take-home points from the document:

  1. For children less than 15 years old who are asymptomatic or only mildly symptomatic with COVID-19, no cardiovascular testing is recommended unless the child had specific cardiac symptoms during their illness. Put another way, universal cardiac evaluation for those patients is unwarranted, particularly because the easiest test to do (ECG) has limited sensitivity for myocarditis.

  2. Those in this age group who experienced moderate symptoms and were not hospitalized, and those who had severe symptoms and were hospitalized, should be evaluated by a pediatrician or a pediatric cardiologist to determine whether risk-stratified cardiac evaluation is indicated.

  3. For athletes 15 and older, the authors recommend that providers follow the adult decision tree proposed in this guideline. Universal cardiovascular testing is also not warranted in athletes in this age group who were asymptomatic or only mildly symptomatic.

  4. Athletes 15 and older who were moderately ill or hospitalized should generally receive testing. If these teens received cardiac evaluation during hospitalization, no further testing would be required if those results were normal.

  5. The final take-home point is that any child or adolescent with multisystem inflammatory syndrome in children (MIS-C) should receive the full cardiac evaluation. Those with abnormal cardiac testing during hospitalization will also need to follow a myocarditis RTP guideline. The need for conducting cardiovascular evaluation universally in children with MIS-C was illustrated in an analysis of a small group of children admitted with MIS-C. Over half of the children had nonspecific ST segment changes on ECG, 60% had evidence of left ventricular systolic dysfunction, and 20% of the patients had a first-degree atrioventricular block.

The recommendations include a useful decision algorithm for testing in high school athletes (Figure 1). Personally, I'd recommend printing it and taping it to your office wall!

Figure 1. Download PDF here

Management of athletes with abnormal tests. Any child who develops new cardiovascular symptoms during any phase of recovery should be evaluated with ECG, echocardiogram, and high-sensitivity troponin I levels. Anyone with positive findings on any of these tests should then move on to cardiac MRI.

Outdoor sports. The committee recommends that decisions to cancel youth outdoor sports should be based primarily on community rates of infection and not potential risk to the athletes. It is not clear that athletes in communities with acceptable rates of COVID-19 infection are at any greater risk.

Can Newborns Room in With a Mom Who Is Infected?

Pediatric clinicians who work in a newborn nursery realize that we have been frequently confronted with the question of what to do with infants who were exposed to or contracted COVID-19 within the first month of life. One recent brief report tested breast milk of 18 nursing mothers with confirmed COVID-19. While the breast milk of one of the mothers was positive for SARS-CoV-2 virus by PCR, that sample did not have viable virus.

A November report identified 66 neonates with confirmed COVID-19 infection using UK surveillance data collected from April through July 2020. These infants were diagnosed at a median of 9.5 days old. While 25% of them were born to a mother with confirmed COVID-19 infection, only 2 of 66 total infants (3.03%) were suspected to have been infected through vertical transmission.

And this illness was not benign. In fact, only 11% of the infected infants were asymptomatic. Hypothermia, poor feeding, and vomiting where the most prevalent symptoms. About one third of the infants required neonatal or pediatric ICU treatment. A similar percentage required some sort of respiratory support. The silver lining is that almost all newborns recovered. One infant did die, but the cause was determined to be unrelated to SARS-CoV-2 infection.

On the basis of the infants studied, vertical transmission appeared rare. The investigators concluded that their data indirectly supported an approach that does not separate mothers and infants when the mom is known to be COVID-19 positive.

A ray of good news as this pandemic rages on.

William T. Basco, Jr, MD, MS, is a professor of pediatrics at the Medical University of South Carolina and director of the Division of General Pediatrics. He is an active health services researcher and has published more than 60 manuscripts in the peer-reviewed literature.

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