COVID-19 Screening Clinical Pathway — Outpatient Specialty Care and Primary Care

COVID-19 Return to Sports Participation for Pediatric Cardiologists and Recommendations for Cardiology Consultation after COVID-19

The following recommendations are based on the recent expert guidelines from the American College of Cardiology, review of published guidelines, and local expert consensus from the Division of Cardiology and Division of General Pediatrics.

For all COVID-19 positive patients, continue to follow CDC guidelines for isolation based on pertinent individual disease criteria.

Recommendations for Pediatric Patient with History of COVID-19 Infection
Note: Recommendations are subject to change based on the latest evidence and CHOP expert consensus, as more information about the cardiac manifestations of COVID-19 in our patients becomes available.
Asymptomatic Patients and Patients with Mild Symptoms	Asymptomatic: testing due to exposure, incidental finding of positive test, etc. Mild symptoms (as defined by the AAP ): < 4 days of fever > 100.4°F and < 1 week of myalgia, chills, and lethargy Regardless of patient’s age, patients should refrain from sports and exercise until 10 days after the positive test result and a minimum of 24 hours without symptoms without fever-reducing medications.
Patients with Moderate Symptoms	This category will typically include patients with moderate symptoms who are managed at home with ≥4 days of fever > 100.4°F or ≥ 1 week of myalgia, chills, or lethargy. However, this category can also apply to hospitalized patients who have only moderate symptoms and no concern for cardiac involvement. < 12 years old Refrain from sports and exercise until 10 days after the positive test result and a minimum of 10 days without symptoms without fever-reducing medications. ≥ 12 years old After 10 days from the positive test result and a minimum of 10 days without symptoms without fever-reducing medications, the primary care provider should obtain an electrocardiogram before clearance for competitive sports. If the ECG is normal and there are no additional cardiac concerns, the patient can return to competitive sports. If the ECG is abnormal, the patient should be referred to pediatric cardiology. For patients who are not involved in competitive athletics, an ECG is not routinely recommended.
Patients with Severe Symptoms Requiring Hospitalization	All patients requiring hospitalization for severe acute COVID-19 symptoms should be referred to outpatient cardiology for evaluation at least 2 weeks after discharge, sooner if cardiac concerns, regardless of age or activity level. Non-ICU admission Restrict from sports and exercise until the initial cardiology appointment. The duration of restriction will be determined at cardiology visit. If an ECG and echocardiogram were not obtained during the admission, these tests should be considered at the initial cardiology visit. At the cardiology appointment, if the patient is asymptomatic with no evidence of current or prior cardiac involvement, it is reasonable to return to activity at that time. ICU admission Restrict from competitive sports for 3-6 months. Patients should be evaluated in outpatient pediatric cardiology with a myocarditis-like management approach: Obtain a baseline echocardiogram and ECG during the initial outpatient cardiology visit, if not obtained during prior hospitalization. Consider a baseline cardiac MRI, particularly if inpatient ECG, echocardiogram, and/or troponin were abnormal or if outpatient ECG and/or echocardiogram are abnormal. Obtain an echocardiogram, Holter monitor, and exercise stress test in 3-6 months in those with a history of myocardial involvement before returning to sports. It’s reasonable to consider obtaining all of these tests for all patients with COVID-19 requiring ICU-level care, regardless of any documented myocardial involvement. Consider a repeat cardiac MRI in 3-6 months if the baseline MRI was abnormal.

For ALL patients who are cleared for return to sports/exercise

Whenever resuming activity (competitive sports, physical education class, recreational activities), patients should slowly advance activity over a minimum of 7 days, and monitor for further symptoms.
Any concern for clinical deterioration or cardiac symptoms should warrant further cardiac evaluation and discontinuation of sports/exercise until further notice.

Multisystem Inflammatory Syndrome in Children (MIS-C)

MIS-C is currently felt to be a post-infectious delayed immune response to prior COVID-19 infection. Patients with MIS-C should be followed by pediatric cardiology outpatient with return to sports dictated by pediatric cardiologist and often by multidisciplinary team.

Refer to CHOP COVID-19 clinical pathways, including further information on evaluation and management of COVID-19 and MIS-C.

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.