404 - COVID-19 and Youth Sports Update, Depression Treatment

From the Literature, the Guidelines, and Question from a Colleague

1) Update: Youth Sports and COVID-19 Infection

Question:

“Since you last covered this in the fall of 2020, is there anything new about ‘clearing’ youth athletes so they can return to sports after contracting COVID-19 or any other COVID youth sports updates?”

Answer:

According to the most recent update of the American Academy of Pediatrics (AAP) guidance dated 4 June 2021, studies from outdoor contact sports, such as football and rugby, confirm low transmission risk from on-field activities, therefore a face mask may not be necessary during outdoor sport-related activities. Most transmission associated with outdoor sports has been related to off-field activities, such as sharing meals and during transportation in private vehicles where people were unmasked or partially masked. For outdoor sports, athletes who are not fully vaccinated should be encouraged to wear face masks on the sidelines and during all group training and competition in which there is sustained contact of 3 feet or less.

Proper use of a face mask for all indoor sports training, competition, and on the sidelines is strongly recommended for people who are not fully vaccinated, except in the case where the mask bears a safety risk. Proper face mask use during indoor sports decreases risk of SARS-CoV-2 transmission to rates as low as with outdoor sports.

The AAP recommends all eligible children be vaccinated for COVID-19. All people, regardless of vaccine status, should consider wearing a face mask in crowded indoor spaces, such as a locker room and during shared transportation. 

For children and adolescents with a history of SARS-CoV-2 infection who have already advanced back to physical activity/sports on their own and do not have any abnormal signs/symptoms, no further workup is necessary.

For those who have experienced a recent infection:

All children and adolescents who test positive for SARS-CoV-2 should notify their healthcare clinician. For a child or adolescent who is either asymptomatic or mildly symptomatic (<4 days of fever >100.4°F, <1 week of myalgia, chills, and lethargy) a phone or telemedicine visit is recommended, at a minimum, so appropriate guidance can be given to the family. All individuals should be instructed on proper quarantine (duration and restricting exposure to other people within the house) and the importance of not exercising while in quarantine.

Recent literature has reported a much lower incidence of myocarditis, 0.5% to 3%, than what was reported earlier in the pandemic. Though less common, this can occur for children and adolescents in the asymptomatic or mildly symptomatic category. Therefore, the phone/telemedicine visit should include appropriate questions about chest pain, shortness of breath out of proportion for upper respiratory tract infection, new-onset palpitations, or syncope. Any child or adolescent who reports these signs/symptoms should have an in-office visit that includes a complete physical examination, and consideration for an EKG should be given prior to clearance to return to physical activity.

For those with moderate symptoms (≥4 days of fever >100.4°F, ≥1 week of myalgia, chills, or lethargy, or a non-ICU hospital stay and no evidence of multisystem inflammatory syndrome in children [MIS-C]), an evaluation by their primary care physician (PCP) is recommended after symptom resolution and completion of quarantine. They should not exercise until they are cleared by a physician. The PCP should review the American Heart Association 14-element screening evaluation (see references) with special emphasis on cardiac symptoms including chest pain, shortness of breath out of proportion for upper respiratory tract infection, new-onset palpitations, or syncope and perform a complete physical examination and an EKG. If cardiac workup is negative, gradual return to physical activity (see below) may be initiated after 10 days have passed from the date of the positive test result, and a minimum of 10 days of symptom resolution has occurred off fever-reducing medicine. If cardiac sign/symptom screening is positive or EKG is abnormal, referral to a cardiologist is recommended.

For children and adolescents with severe COVID-19 symptoms (ICU stay and/or intubation) or MIS-C, it is recommended they be restricted from exercise for a minimum of 3 to 6 months and obtain cardiology clearance prior to resuming training or competition.

The AAP recommends no one return to sports/physical activity until they have completed quarantine, at least 10 days from symptom resolution has passed, they can perform normal activities of daily living, and they display no concerning signs/symptoms.

All children younger than 12 years may progress back to sports/physical education classes according to their own tolerance. For children and adolescents 12 years and older, a graduated return-to-play protocol is recommended. Here is a guide for a minimum protocol (see 2^nd reference).

• Stage 1: Day 1 and Day 2 - (2 Days Minimum) - 15 minutes or less: Light activity (walking, jogging, stationary bike), intensity no greater than 70% of maximum heart rate. NO resistance training. 
• Stage 2: Day 3 - (1 Day Minimum) - 30 minutes or less: Add simple movement activities (eg. running drills) - intensity no greater than 80% of maximum heart rate. 
• Stage 3: Day 4 - (1 Day Minimum) - 45 minutes or less- Progress to more complex training - intensity no greater than 80% maximum heart rate. May add light resistance training. 
• Stage 4: Day 5 and Day 6 - (2 Days Minimum) - 60 minutes - Normal training activity - intensity no greater than 80% maximum heart rate. 
• Stage 5: Day 7 - Return to full activity/participation (ie, contests/competitions).

Mark’s Comments:

This guidance from the AAP has continued to become more specific fall as additional studies help us understand the longer-term impact of COVID infection in children and adolescents. One important take-away for me is the importance of a complete COVID symptom history and the reassurance that not all these children need a more extensive (and expensive) cardiac imaging work-up. My personal experience is that some parents of these child athletes require additional reassurance, and the updated AAP guidance is very timely in this regard.

At the same time, we’ll need to closely follow the increasing reports of myocarditis potentially resulting from the mRNA vaccine in adolescents and young adults. Though these cases appear to be self-limited, they certainly may impact how these persons are managed post-vaccine when it comes to return to sports ( AAP News Story )

References:

• AAP COVID-19 Interim Guidance – Return to Sports. Last updated 6/4/21. Link
• Elliott N et al. Infographic. Graduated return to play guidance following COVID-19 infection. British Journal of Sports Medicine 2020;54:1174-1175. Link
• ACC/AHA Recommendations For Congenital and Genetic Heart Disease Screenings in Youth. ACC News. 15 September 2014. Link

From the Literature

2) Psychotherapy vs. Pharmacologic Therapy for Depression

Depression is very commonly encountered and treated in primary care. The US Preventive Services Task Force feels comfortable recommending screening for depression because of the demonstrated ability of primary care to manage depression. It is often recommended that psychotherapy (counseling) be prescribed alongside medication, but in practice, this often does not occur.

Researchers in the Annals of Family Medicine performed a network meta-analysis to evaluate the effectiveness of psychotherapy compared with pharmacologic therapy for the treatment of depression. As a reminder, network meta-analysis is a statistical technique to compare multiple interventions against each other using study data that often describes only comparisons of a treatment vs. placebo, or just one treatment with another. Ideally, we would base these comparisons on large comparative effectiveness studies, but those are rare, so this technique can help us with the comparisons we need.

The authors used a previously created database of RCTs on pharmacotherapy that draws from multiple literature databases. They created solid inclusion and exclusion criteria, graded the quality of the studies, and looked for heterogeneity. The primary outcome they decided upon for the meta-analyses was “50% reduction in depression symptoms by the end of psychotherapy,” but they also looked at remission and difference in depression scale scores.

All active treatments (psychotherapy, pharmacotherapy and combined) worked better than placebo, waitlist, or care-as-usual controls. There was an obvious trend toward combined treatment working better than either psychotherapy or pharmacotherapy over all the data, but this difference was only statistically significant for combined treatment vs. psychotherapy for the primary outcome only. Acceptability of the different treatments to the patients did not differ. The authors note several limitations – risk of bias in the included studies, heterogeneity in the studies, and some limited evidence for some of the comparisons.

John’s Comments:

This is weak-to-moderate evidence that any one of pharmacotherapy, psychotherapy, or the combination of both are helpful for depression. It’s probably good practice to recommend both, given that trials frequently included both, but availability and accessibility of psychotherapy is a frequent challenge. Acceptability ratings did not seem favor any particular approach.

Reference:

Cuijpers P et al. Psychologic Treatment of Depression Compared With Pharmacotherapy and Combined Treatment in Primary Care: A Network Meta-Analysis. Ann Fam Med. 2021 May;19(3):262–70. Link

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Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org