Is it safe for my child to return to play after a COVID infection? 

Children, like adults, want to get back to life as usual as soon as possible after a COVID infection. Everyone can mask up and sit at a desk, but what about gym class and organized sports?

Current CDC guidelines state students can return to school after five days. Some schools require a doctor to sign off before allowing students with mild or asymptomatic infections to rejoin organized play well in advance of the previously recommended 14-day waiting period.

In response, a committee of pediatric cardiologists at Columbia University updated return to play guidance to aid health care providers. Rachel Weller, MD, assistant professor of pediatrics at Columbia University Vagelos College of Physicians and Surgeons, adapted that guidance for parents and caregivers:

Asymptomatic and mild cases

Children and adolescents who were asymptomatic or mildly symptomatic should have at least a telephone call with their pediatrician.

Overall, says Weller, the group’s advice is: It is reasonable to resume full play seven days after a positive COVID test and 72 hours after resolution of symptoms if your child has no symptoms of myocarditis (inflammation of the heart).

It is rare for children with asymptomatic, mild, or moderate COVID infection to develop myocarditis, but it can occur, says Weller.

Symptoms of myocarditis can arise at any point in the first months following a COVID infection but are more likely to show within seven days after a positive COVID test. A person with myocarditis may develop an abnormal heart rhythm or even experience sudden death during physical activity.

“I don’t want to scare parents, because heart issues only arise in less than 1% of kids who get COVID,” says Weller. “But parents need to be on the lookout, because the issue can be serious and it’s happening to otherwise healthy children who had no symptoms or mild reactions to the infection." 

What to look for

Look for symptoms that are new and appear days or weeks after a COVID infection, especially:

• Chest pain    
• Fainting or near-fainting    
• Fatigue (exercise intolerance)    
• Palpitations  
• Significant shortness of breath    

Any child with these symptoms should be seen by their pediatrician and get an ECG.

Moderate cases  

Children with moderate infection (at least four days of fever and/or prolonged muscle aches/tiredness) should have an in-person visit with their pediatrician. “These children need to wait 10 days to return to play,” Weller says.

Children returning to an organized sport need a screening ECG as well, even if they have no symptoms of myocarditis. Weller adds: "It is reasonable for pediatricians to do an ECG even for PE class clearance if they have any concerns, ” (a recommendation that varies slightly from AAP guidelines that recommend ECGs for all children with moderate COVID).

See your pediatrician    

“They’ll get sick and then they will be fine” is something Weller has heard parents say, but that does not apply when it comes to COVID. If your child or adolescent has concerning symptoms at any point in the first couple of months following COVID infection, you should see your pediatrician. The doctor will likely do an ECG and may refer you to a cardiologist for further evaluation.   

Even without heart involvement, it is not uncommon to be deconditioned following COVID infection, so your child should be allowed to self-limit and ease more slowly into full activity if needed.