While there is less data about pediatric patients, emerging evidence shows that people infected with COVID-19 are at increased risk for myocarditis. Because of this, it is important that pediatricians appropriately evaluate patients before they are cleared to return to play as sports resume after a prolonged COVID-prompted off season.
Patients should be seen in the provider’s office for an in-person, formal evaluation and physical exam to determine clearance, recommend Drs. Kornswiet and Koutures. The following decision tree can aid in triaging patients, as well as providing consistent patient care. This decision tree is applicable to middle and high school athletes, as well as to those who compete in high-exertion activities and to other patients on an individual basis.
The California Interscholastic Federation recommends that if a patient’s infection was over three months ago, they had an asymptomatic, mild or moderate illness, and the patient has regained fitness or is back to full activity without symptoms, then they can return to sports as long as they have an active/recent preparticipation physical exam.
Once an athlete is cleared for a return to sports, Drs. Kornswiet and Koutures recommended that they go through a gradual and step-wise return to play. This is similar to the return-to-play protocol for concussions, and should be performed under the supervision of a physician and athletic trainer, if possible.
Each phase should last at least 24 to 48 hours and should not cause return of symptoms. If the athlete/student experiences a return of symptoms or develops unexpected fatigue, dizziness, difficulty breathing, chest pain/pressure, decreased exercise tolerance, or fainting, then they should stop their return progression and return to their physician for further evaluation.
These protocols are not substitutes for medical judgment, and additional queries should be directed to pediatric cardiologists or sports medicine specialists.
Following are more general return-to-sports guidance for parents and coaches:
While most medical providers are familiar with Return to Play laws – a step-wise progression addressing when student athletes with concussions should return to sports/physical activity – there is no similar legal process for “Return to Learn” guidelines addressing when students with concussions should return to school.
Further, a study in the December 2016 Pediatrics found that only a few states have Return to Learn concussion laws, and these varied in delineation of responsibility. Some of the laws were restricted to student athletes, excluding students who sustained non-sport related concussions.
When returning a student to the classroom after a concussion, we try to balance stimulation levels and worsening of symptoms, explains Dr. Chris Koutures, a board certified pediatrician and sports medicine specialist at CHOC. While too much cognitive exertion can lead to headaches, problems concentrating, fatigue and trouble with emotional control, over restriction from classroom and academic activities can result in social isolation and anxiety about falling behind or lower grades that can also slow the recovery process.
“Returning to the classroom after a concussion optimally takes a team approach including the student, family, medical and education teams,” Dr. Koutures says. “Flexibility and creativity in paying attention to individual student needs and concerns can make this process more rewarding for all parties.”
Dr. Koutures advises the patient’s care team to follow CHOC’s recommended six stages for returning a student to school after a concussion, including the following added guidelines:
Step-wise Return to Learn Progression
Step 1: No formal academic activity
Recent studies suggest that full or prolonged limitations in cognitive activity may actually delay recovery
In first few days after concussion, allow 15-20 minute intervals of single-task activities that do not provoke symptoms and are not excessively taxing
Listen to light music
Draw or color
Passive television or movies (at home), larger screen preferred, lower volume
Some texting, smartphone use; want to balance maintaining key social contacts with not having symptom-flare
Conversations with 1-2 other people
Separate the 15-20 minute bursts of activity by 30-40 minutes minimum of non-cognitive activity
If symptoms flare before 15-20 minute limit, stop activity and try again later
If patient can handle 2-3 periods of 15-20 minute activity over the course of day, can consider advancing toward partial return to school
Step 2: Light academic activity
Attend 1-2 periods or 1-2 hours of school
Select consecutive classes; have child help make decision
No physical education or other activity classes
Caution with more noisy classes such as woodshop, music/band, chorus
Tend to avoid first class in morning to allow more sleep and arrival at school without busy parking lot and hallways
Main goal: be in class; no responsibility for note-taking, participating in class /responding to teacher, in-class work, homework or testing
Audible learning (most kids handle this better than visual learning after a concussion)
Should have pre-printed notes for reference or have others take notes and share
Sit away from louder students, windows, projectors, or other light/noise stimulation
Sit close to teacher
Allow to wear earplugs and sunglasses as needed
May allow brief 1-2 minute periods of putting head on desk for rest
May leave class early to avoid the noise and commotion of hallways during passing periods
Step 3: Increased academic activity
Expand day to 3-4 periods or hours per day
Incorporate break periods (nutrition break, lunch)
Have quiet place to rest
Recommend against assemblies or rallies due to noise stimulation
Continue to avoid physical education or activity classes
Main goal is to be in class and handle longer day; still not responsible for note-taking, participating in class/responding to teacher, in-class work or homework
Step 4: Full-time attendance
Full-day attendance without activity or other higher-stimulation classes
May expect some increased fatigue at end of school day
If student wants to nap after school, limit to no more than one hour
May start to take own notes, though helpful to have pre-printed teacher’s notes or other student notes
Incorporate “to do” lists with short-block (10-15 minute) work periods followed by short (5 minute) breaks
Break period and breaks in class (especially if block schedule) may still be needed
If possible, move most challenging courses to time of day when student feels the best
Step 5: Return to Majority of Academic Activities
Once handling full day attendance, can resume taking notes in class, verbal responses to teacher, and in-class work
May begin homework starting with limits to 30-60 minutes a night and priority on essential concepts that are needed for eventual testing or continuity of learning
Waive any projects, papers, essays or other assignments that are not required for future learning needs
Try to limit burden of make-up work; focus should be on those assignments that are necessary for future learning
Sequential classes (math, foreign languages, science) tend to be the most challenging for make-up work
No tests or quizzes at this stage
Audible learning – listen/speak responses vs. writing, dictating work, audiobooks may be more favorable at this point
Step 6: Return to Full Academic Activity
Full-day attendance without symptoms, fulfilling all in-class duties and completing usual homework assignments
Can resume tests and quizzes
Strongly consider waiving missed tests or quizzes
Combine missed tests or quizzes to allow more quick completion of make-up work
Allow student to take missed tests/quizzes to gain exposure/mastery of material without being graded, or only receive grade if results are in usual level of achievement
Assign grades at end of grading period based on level of work prior to concussion
May need more time for test completion
May need individual room placement for testing
May limit testing/make-up testing to one test per day
May allow open book, use of notes, word banks or home-based testing
Consider alternate forms of testing such as spoken test, or multiple choice vs. longer essay responses that might be more taxing for the student
Students may still benefit from more audio learning
Can resume physical education (with physician release) and activity courses.
To contact Dr. Chris Koutures, please call 714-974-2220.