Anna Turska-Kmieć1,2,3
Daniel Neunhaeuserer4,5Artur Mazur2,6,7
Łukasz Dembiński2,6,8
Stefano del Torso6,9
Zachi Grossman6,10,11
Shimon Barak12,13
Adamos Hadjipanayis6,14,15Jarosław Peregud-Pogorzelski2,16
Tomasz Kostka17,18Andrzej Bugajski18,19
Gottfried Huss12,20Monika Kowalczyk-Domagała1,21
Justyna Wyszyńska22*†
- 1Department of Cardiology, Children’s Memorial Health Institute, Warsaw, Poland
- 2Polish Paediatric Society, Warsaw, Poland
- 3Working Group on Sports Cardiology, Polish Cardiac Society, Warsaw, Poland
- 4Sports and Exercise Medicine Division, University of Padova Department of Medicine, Padova, Italy
- 5Clinical Network of Sports and Exercise Medicine of the Veneto Region, Padova, Italy
- 6The European Academy of Paediatrics, EAP, Brussels, Belgium
- 7Institute of Medical Sciences, Medical College of Rzeszów University, Rzeszów, Poland
- 8Department of Paediatric Gastroenterology and Nutrition, Medical University of Warsaw, Warsaw, Poland
- 9Childcare Worldwide, Padova, Italy
- 10Adelson School of Medicine, Ariel University, Ariel, Israel
- 11Maccabi Health Services, Pediatric Clinic, Tel Aviv, Israel
- 12The European Confederation of Primary Care Paediatricians (ECPCP), Lyon, France
- 13Dana-Dwek Children’s Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- 14School of Medicine, European University Cyprus, Nicosia, Cyprus
- 15Paediatric Department, Larnaca General Hospital, Larnaca, Cyprus
- 16Department of Paediatrics, Paediatric Oncology and Immunology, Pomeranian Medical University, Szczecin, Poland
- 17Department of Geriatrics, Medical University of Lodz, Lodz, Poland
- 18The Polish Society of Sports Medicine, Wroclaw, Poland
- 19Department of Physiotherapy, College of Physiotherapy, Wroclaw, Poland
- 20Kinder-Permanence Hospital Zollikerberg, Zollikerberg, Switzerland
- 21Working Group on Paediatric Cardiology, Polish Cardiac Society, Warsaw, Poland
- 22Institute of Health Sciences, Medical College of Rzeszów University, Rzeszów, Poland
The European Academy of Paediatrics (EAP) and the European Confederation of Primary Care Paediatricians (ECPCP) emphasize the importance of promoting healthy lifestyles within the pediatric population. Many health professionals have questions concerning adequate levels of physical activity for both the healthy pediatric population and for those who may have specific complications. Unfortunately, the academic literature that provides recommendations for participation in sport activities within the pediatric population that have been published during the last decade in Europe is limited and is mainly dedicated to specific illnesses or advanced athletes and not toward the general population. The aim of part 1 of the EAP and ECPCP position statement is to assist healthcare professionals in implementing the best management strategies for a pre-participation evaluation (PPE) for participation in sports for individual children and adolescents. In the absence of a uniform protocol, it is necessary to respect physician autonomy for choosing and implementing the most appropriate and familiar PPE screening strategy and to discuss the decisions made with young athletes and their families. This first part of the Position Statement concerning Sport Activities for Children and Adolescents is dedicated to healthy young athletes.
Introduction
The European Academy of Paediatrics (EAP) and the European Confederation of Primary Care Paediatricians (ECPCP) emphasize the importance of promoting healthy lifestyles for the pediatric population within every age range. The main conclusion from the study entitled “Youth sport participation trends in Europe - An output of Erasmus+,” which presented the findings of an international study on the involvement rates of youth in organized sports during 2017–2020, was a noticeable decline in participation in most sports for boys and girls (1). Therefore, there is an urgent need to increase support and retention of participation in sports from a young age along with essential physical activity (PA) counseling at every visit to the doctor.
Physical activity (PA) is essential for appropriate physical, emotional, and psychosocial growth of the pediatric population as well for patients with different diseases (2–4). The benefits of participation in sports are well-known in the scientific literature (2, 3, 5–8). The European Society of Cardiology (ESC) supports PA as a Class IA guideline for the prevention and management of cardiovascular (CV) disease (9). In 2022, the World Health Organization (WHO) suggested that children between the ages of 5 and 17 years accumulate a minimum of 60 min of moderate-to-vigorous PA (MVPA) per day that includes a variety of endurance activities (10). The WHO also recommends performing regular vigorous intensity aerobic activities and bone and muscle-strengthening activities at least 3 days a week for all age groups (5, 10, 11). Despite the widely accepted benefits of PA, recent data (2020) showed that the majority (81%) of children aged 11–17 years participate in MVPA less than 1 h a day with girls being less physically active than boys in most countries (12). Restrictions during the COVID-19 pandemic have affected children's PA levels. Therefore, promoting PA in the pediatric population should be a priority to recover pre-pandemic activity levels (13, 14).
Aim
The sudden death of a young athlete (sudden athlete death, SAD) is a tragic and rare event, reported to occur in one to two cases out of 100,000 athletes each year (15, 16). A lack of knowledge of the current guidelines diminishes confidence in identifying children who may be at increased risk of injury (17–20) or even SAD (16, 21) as a result of participation in sports (22). Unfortunately, the academic literature that provides recommendations for participation in sport activities within the pediatric population that have been published during the last decade in Europe is limited and is mainly dedicated to specific illnesses or advanced athletes and not toward the general population. The aim of this EAP and ECPCP statement is not to present obligatory recommendations for sport pre-participation evaluation (PPE), but rather to summarize information based on analyses of the relevant literature and expert opinions regarding sports and exercise. This EAP statement reviews the key points of a patient's medical history and physical examination that should alert the clinician and guide healthcare professionals to make the best decisions for sports safety in their practice.
Recommendations for physical activity and sport participation for the population of children and adolescents published in the literature
In 2019, the American Academy of Pediatrics (AAP) published “The Fifth Edition of PPE Monograph,” which is an approach to sports PPE that should be considered by healthcare professionals as a guide to help recognize whether a particular medical condition requires special care in young athletes (23).
In Europe, literature concerning sports PPE guidelines in the pediatric population is limited:
• In 2011, recommendations for PA, recreational sports, and exercise training for children and adolescents with congenital heart disease were published by the Exercise, Basic, and Translational Research Section of the European Association of Cardiovascular Prevention and Rehabilitation, the European Congenital Heart and Lung Exercise Group, and the Association for European Paediatric Cardiology (AEPC) (24).
• In 2012, the Polish Society of Sports Medicine (PSSM) published a position regarding age criteria during qualification for training in selected sport disciplines (25).
• In 2017, the EAP published a resolution related to health, integrity, and doping in sports for the pediatric population and young adults (26).
• Cardiovascular pre-participation screening recommendations for young athletes were published in 2017 by the AEPC (27).
• Guidelines for participation in competitive sports for patients with congenital heart disease (CHD) older than 16 years were published in 2020 by the Section of Sports Cardiology and Exercise of the European Association of Preventive Cardiology Group (EAPC) and the ESC working on adult CHD and AEPC (28). In 2020, the European Childhood Obesity Group and the EAP published specific birth to adolescence age-appropriate PA recommendations based on a search of the published literature (3).
• In 2021, the European Federation of Sports Medicine Associations (EFSMA) along with nine other organizations published “Pre-participation medical evaluation for elite athletes: EFSMA recommendations on standardized pre-participation evaluation form in European countries” (29).
• In 2021, the ESC published guidelines on the task force for cardiovascular disease prevention in clinical practice (30).
Age-specific pre-participation cardiovascular evaluation (PPCE) proposals for Swiss pediatric and adolescent athletes (under 18 years of age) were published in 2022 (31).
Definitions
Physical activity and sports
According to the WHO glossary of terms, PA is defined as “any active bodily movement resulting from the contraction of skeletal muscles that raises energy expenditure above resting metabolic level” (5). The types of PA included aerobic exercise, muscle strengthening, balance, and flexibility exercises (32) to be performed at least three times per week as part of minimum 60 min daily routine (33). The dose of exercise can be determined using the frequency, intensity, time, and type of exercise (FITT) principles (34). Detailed guidelines for following FITT principles for PA within the healthy pediatric population are described in literature (34, 35).
Classification of sports and athletes
There are various types of sport activity which can be defined under different settings (5) such as:
• Leisure sports: recreational PA without pressure to play, continuous play, or play at a higher intensity based on the willingness of the subject. Any participants may stop or lower the intensity of their involvement at any time.
• Competitive sports: organized, competitive, and skillful PA within established rules of the sport.
• Exercise training: specialized, structured, planned methods and programs of PA used to enhance a participant's physical abilities.
A young athlete is defined as an individual, either amateur or professional, who participates in regular training and official sports competitions (36, 37). All PA can be described according to dynamic and static components, as shown in Table 1 (38).
Table 1. Classification of sports according to dynamic and static components (37).
Exercise trainings are specialized and planned methods and programs of PA for increasing functional capacity, performance, or cardiorespiratory fitness (39, 40). Recommendations should describe the amount (frequency, intensity, duration) and types of PA (4, 28, 34). Three stages of all exercise training are (1) a 10–15 min warm-up period, (2) the specific exercise training, and (3) a 10 min cool-down period with stretching. Adequate recovery time should be provided between training sessions (12–48 h depending on the intensity of the training session and conditioning of the participant).
Age criteria for qualifying children and adolescents for participation in sports
General age criteria for participation in sports
Pediatric and adolescent athletes who are younger than 18 years of age may be defined as participating in competitive sports at a high level if they are practicing in a team setting for at least 6 h per week (31). Not all exercises have the same consequences for an individual's health status, whether positive or negative (40, 41). The peak age range for involvement in sports is between the ages of 10–14 years, although currently athletes begin specialized training at an increasingly younger age (42). This may be due to greater pressure for achievement from coaches or parents (43).
In 2014, the United States Olympic Committee along with the National Governing Bodies used the long-term athlete development principles to create the American Development Model (42). They created five stages including the following: (1) discover, learn, and play (ages 0–12 years); (2) develop and challenge (ages 10–16 years); (3) train and compete (ages 13–19 years); (4) high performance or participate and succeed (ages ≥15 years); and (5) mentor and thrive (for life).
In 2012 in Europe, the Polish Society of Sports Medicine (PSSM) published its position regarding age criteria during qualification for training in selected disciplines in the pediatric population (25). The criteria were developed depending on developmental age, because calendar age is not always an accurate indicator of a child's growth (44). General age criteria for participation in sports proposed by the PSSM for children and adolescents are as follows (25): (1) younger than 6 years (all disciplines based on natural forms of movements in the form of game and play involving movement); (2) older than 6 years (the disciplines based on natural forms of movement, developing coordination of movement that does not exert a selective load on the skeletal system); (3) older than 8 years (sport disciplines that develop agility, speed, and movement dynamics); (4) older than 10 years (sport disciplines that develop endurance and strength); (5) older than 13 years (disciplines involving a full range of endurance training); and (6) older than 15 years (disciplines in which a full range of static strength exercises can be introduced).
Individual differences in growth and maturation can lead to unforeseen consequences in competitive sports and an increased risk of injury, especially in athletes who are constitutionally smaller and/or delayed in maturation. Therefore, there has been a long tradition of proposals for selecting athletes based on physical characteristics rather than chronological age. This strategy is called “bio-banding” and involves grouping and/or assessing athletes based on size and/or maturity status rather than chronological age (45). According to Tanner, biological age determined by puberty stages (46, 47) is more appropriate than chronological age and should be used in assessments of young athletes. Maturation is the process of a child's growth toward obtaining adult stature. All humans experience maturation differently. Females tend to mature faster than boys, but post-pubertal boys will experience greater increases in strength and power due to testosterone and other androgen hormones. Maturation should be measured in young athletes to properly monitor their growth and wellbeing (48). While bio-banding puts athletes into groups based on physical attributes, it does not preclude the inclusion of psychological and/or technical skills. For example, boys that may have matured early may be discouraged from competing or training with older participants if they lacked the technical competence and/or mental maturity to provide a safe and positive experience (49). Implications of somatic growth and maturation for sport participation, overuse injuries in adolescents during times of rapid growth, and concepts of bio-banding for both training and competition based on biological maturation for youth sports (50, 51) will be discussed in a separate part of the Position of the European Academy of Paediatrics and the European Confederation of Primary Care Paediatricians.
Pre-participation physical evaluation
The main scope of sports PPE is to maximize safe participation. It should be individually adjusted to the participant especially during obligatory general pediatric consultations between the age of 0 and 18.
The objectives of the PPE are as follows (23, 52–56):
• Primary objectives: disclosure of defects that may limit participation and determine conditions that may be life-threatening or disabling.
• Secondary objectives: an indication of the general health of a child, examination of the level of maturation, provisions enabling an opportunity to answer questions, and introduction of the athlete into local sports.
• Other objectives: classification of an athlete according to individual qualifications, compliance with legal and insurance requirements for athletic programs, and provision of opportunities for children to compete.
In European countries, local and state requirements determine who has the authority to perform a PPE. General practitioners are responsible for conducting a PPE for children wishing to participate in sports, but in some countries, the determination of sport eligibility depends on the opinion of sport and exercise medicine (SEM) specialists, especially for top-level competitive sports (29, 57–62). The utility of the sports PPE in healthy populations has been questioned in recent years. The determination of relative contraindications should be made by an attending physician, who decides whether the patient is eligible for competitive sports or if further specific examinations are required. Although 3.2%–19.2% of athletes have a significant disclosure during the PPE, only 0.3%–1.3% of athletes are ultimately disqualified from involvement based on findings from the PPE (62–64). The Italian pre-participation evaluation program, diagnostic yield, rate of disqualification, and cost analysis, was published in 2020 (65). The PPE is commonly required by sports organizations to fulfill legal and insurance requirements for involvement in competitive sports, and mainly SEM specialists are qualified to conduct such PPEs (29).
The examination should be performed several weeks before a sporting event allowing time for additional examinations or treatment if needed. The AAP recommends a PPE at least 6 weeks prior to the beginning of the season to allow additional assessment and/or rehabilitation prior to competition (66). This may be too short of a time window because multiple specialists often collaborate with each performing a specific evaluation. The primary care physician needs to have time to assimilate all of the information for clinical decision-making and pre-competition screening.
Depending on governmental, state, or sport society requirements, a PPE should be repeated at least every 1–2 years or more frequently for selected sports or for selective health problems in athletes, especially in top-level athletes (59, 67, 68).
Forms of pre-participation physical evaluation
The diagnostic components of PPE are health status, anthropometry, functional capacity, and exercise capacity. For the PPE, both the American and European Societies currently recommend a thorough investigation of personal history, family history, and a limited physical examination to determine the general health of the athlete (23, 29, 55, 59, 64, 66). The physical assessment should include vital signs such as visual acuity and cardiovascular, pulmonary, abdominal, skin, genitalia, neurologic, and musculoskeletal examinations. Parental verification of personal and family history is also recommended.
The EFSMA emphasizes the need for an implementation of a standardized PPE among European countries to ensure the best care for adult athletes (29). Until now, very few reports on periodic health evaluations by PPE in adolescent elite athletes exist (68–70). In 2009, the International Olympic Committee published a Consensus Statement on the Periodic Health Evaluation of Olympic athletes, explaining the purposes and procedures of the PPE in adults (68). The youth PPE was shown to be efficient in diagnosing different disorders, enabling rapid treatment in 12% of Italian Olympic athletes (69). The AAP published standardized physical examination forms as tables with questions about family and athlete history and physical exams, as well as for young athletes with special needs for clearance decisions concerning participation in sports (23).
The pre-participation evaluation does not only focus on elements that determine known problems that affect sport involvement (71). During a PPE, a consulting physician can also educate the participants about injury prevention or concussion, first-aid and external defibrillator–cardioverter support performance, dietary counseling (72), and the effects of nutritional supplements (73). Finally, the PPE may provide an appropriate approach for preventing any doping practices (26).
The past several years, especially during the COVID-19 pandemic, has seen a rapid growth of electronic sports (eSports) media, thanks to the increasing availability of online games and broadcasting technologies (74), and numerous injuries may occur in the participants (eAthletes) (75). The potential benefits of a pre-participation evaluation and injury prevention program in eSports will be discussed in a separate part of the Position of the European Academy of Paediatrics and the European Confederation of Primary Care Paediatricians.
General considerations during a PPE to assess the overall health of a young athlete
wIt has been reported that in up to 58% of young athletes who do not positively pass the PPE screening, the decision to deny may be based on medical history alone or dizziness with exercise, history of asthma, body mass index (BMI), elevated systolic blood pressure, visual acuity, heart murmur, or problems detected during musculoskeletal examination (76). A pre-participation health evaluation in a cohort of adolescent athletes competing in Youth Olympic Games showed that PPE led to a diagnosis of pathological conditions in 12% of the population (69). The most prevalent diseases identified were cardiovascular and pulmonary diseases (4.5% each), followed by endocrine alterations (2%) and infectious, neurological, and psychiatric disorders (0.4% each). Cardiovascular disease was found in 3.9% of elite adult athlete cohort participants who underwent a comprehensive cardiovascular evaluation prior to participation in the Olympic Games (77).
Personal history
Personal history should identify past red flags and present medical conditions as well as previous surgeries and associated consequences such as past injuries, history of passing out, episodes of syncope or dizziness, any medicines currently being taken, vaccinations, history of allergies and anaphylaxis, infection diseases, headache, seizures, and any potential cardiovascular warning signs (high blood pressure, heart murmur, high cholesterol, myocarditis) (23, 56). Boys should be diagnosed for testicular pain. Girls should be asked about their menstruation. The physician should also inquire about smoking and vaping, alcohol intake, drugs, diet pills, or supplements, including steroids.
It is very important during a PPE to inquire about the actual type, amount, and intensity of exercise training, associated chest pain or heart palpitations experienced during or post exercise, trouble breathing during exercise, dizziness or syncope during exercise, and the presence of excessive, unexpected, or unexplained fatigue during exercise.
During a PPE, the consulting physician should inquire about dietary habits and eating disorders. Suggested diets for young athletes were presented in a Position Statement of the American Dietetic Association, Dietitians of Canada, and the American College of Sports Medicine (72). Further important components of a PPE are screening for mental health disorders (78). A list of recommended personal history questions from different systems during PPE in young athletes are summarized in Table 2.
Table 2. List of recommended personal history questions from different systems during sports PPE in young athletes.
Family history
The PPE family history is designed to recognize athletes at risk, especially in those with a family history including SAD. Most sudden deaths have been attributed to congenital or acquired cardiovascular malformations (36, 79). Other causes of sudden death include heat stroke, cerebral aneurysm, asthma, commotio cordis, and sickle cell trait (80). Any athlete with a family history of the following conditions requires a full evaluation and cardiological follow-up (23, 24, 28, 29, 59, 81, 82). If anyone in the athlete's family:
• Died of heart problems or had sudden cardiac arrest before the age of 50 years or died for no apparent reason before the age of 50 years [to include sudden infant death syndrome (SIDS), unexplained car accident, drowning].
• Had any type of heart problem, primary pulmonary hypertension, arterial hypertension, family and hypercholesterolemia.
• Had syncope, presyncope, or unexplained seizures.
• Had significant arrhythmia, an ablation procedure, an implanted pacemaker, or defibrillator.
• Had exercise-induced asthma.
• Had any of the following genetic disorders including hypertrophic cardiomyopathy (HCM), dilated cardiomyopathy (DCM), arrhythmogenic right ventricular cardiomyopathy (ARVC), Marfan syndrome, and Ehlers–Danlos syndrome and channelopathies such as Brugada syndrome (BRS), long-QT syndrome (LQTS), or short-QT syndrome (SQTS).
Sudden death in young athletes is rare and is usually caused by a genetic or congenital structural cardiac disorder (83–85), so detailed family history may help in identifying athletes especially at risk of primary arrhythmia syndromes (23, 27, 67). The issues raised within a family history may be quite obscure to the athlete and family, but young athletes and their parents should still be informed by their physician why such data from the PPE are essential for lowering SAD risk. Importantly, any abnormal finding in the family history and/or physical examination including abnormal prior cardiovascular testing results and a positive family history including premature death (<50 years) and/or genetic cardiomyopathy in a first-degree relative requires further investigation, as suggested by international guidelines (15, 36).
Significant elements of a physical examination
Physical examinations must primarily screen the musculoskeletal, cardiovascular, and nervous systems. Abnormal breath sounds in the lungs should be diagnosed. The PPE may also include a dental and vision evaluation (risk of soft tissue lesions). The evaluation of vision can be performed using a standard vision chart (standard Snellen eye chart) with specification on the use of glasses or contact lenses.
A critical component of a PPE is an anthropometric examination that includes somatoscopy, taking into account measurement of weight, height, BMI, sitting height, body composition, and girth measurements (29, 85, 86). Table 3 contains a summary of significant elements of a physical examination from different systems during a sports PPE.
Table 3. List of significant elements of physical examination during sports PPE.
Musculoskeletal system
Evidence for injury incidence and the long-term effects of participating in sports in the pediatric population are limited (17, 18, 87, 88). A musculoskeletal assessment is recommended to examine joints (89, 90), physical function (flexibility, posture, gait, muscle strength, joint laxity), and regional abnormalities (spine, upper extremity, lower extremity) (55, 62, 91). Of the conditions identified during the PPE, 14% required follow-up before clearance for participation (92, 93).
The first component of the orthopedic PPE is a complete history of previous injuries and surgeries. A previous musculoskeletal injury is a major risk factor for re-injury, especially if the original injury was not rehabilitated properly (92, 94).
The second component of the orthopedic PPE is the physical examination. The examination should evaluate spinal anomalies, deformity, and back pain (95). Back pain was reported in about 8% of young teenage athletes mainly from combat sports, team sports, explosive strength sports, and endurance sports (96). It is known that injury in anatomic regions such as the knees, ankles, and shoulders have a higher risk of future injury (97).
Suggested examples of quick musculoskeletal examinations are offered by the American Medical Society for Sports Medicine (AMSSM) in online educational resources (98). In 2021, the American College of Sports Medicine published Musculoskeletal and Sports Medicine Curriculum Guidelines for Pediatric Residents (99).
Nervous system
The neurological assessment is focused on the abnormal conditions observed during present and previous examinations (100, 101). Youth with a history of concussion should have a neurological assessment (102). Vision and/or hearing loss must be corrected, and consultation with an ophthalmologist or laryngologist may be necessary.
Abdomen
An abdominal assessment can be brief in the absence of a significant history of gastrointestinal (103–106) or nephrological diseases (81, 107–109). Splenic enlargement and history of recent infectious mononucleosis (Epstein–Barr virus infection) are temporary contraindications to sports because splenic rupture is a risk (110). An examination for boys should include assessment of the groin and genitalia. Privacy and chaperones should be present when such evaluations are included, asking for their consent (a second healthcare professional should stay in the room during these examinations). Genitourinary assessment in boys is particularly justified in the case of collision sports, because it is necessary to further protect boys having a single testicle.
Cardiovascular system
Most of the cases of SAD occur in individuals with a pre-existing cardiac abnormality, and in young athletes (<35 years), instances of SAD are mostly due to inherited or congenital cardiac disorders. In 2005, the Study Group of Sports Cardiology of the Working Group on Cardiac Rehabilitation and Exercise Physiology and the Working Group on Myocardial and Pericardial Diseases of the ESC published a common European protocol for cardiovascular pre-participation screening of young competitive athletes for the prevention of SAD which are termed “the Lausanne recommendations” (111). A position paper from 2017 promoted by the EHRA, and the EACPR reviewed the evidence regarding the appropriate diagnostic methods to determine selected heart conditions at risk in SAD (15).
It is obligatory during a PPE to inquire about cardiovascular disease in family history (112, 113) with a high life-threatening risk of cardiac arrest during exercise in young athlete (114). Since 1982, it has been mandatory for every Italian competitive athlete to undergo an annual PPE that includes an assessment of the CV system including non-CV evaluations to identify diseases that pose a risk of SAD during sports or other conditions that may threaten the athlete's health (113, 115). The ESC (111) and the AHA (116) suggested the adoption of a 14-element SAD screening tool during the PPE that contains medical history questions and four assessment elements. Table 4 presents a proposed set of screening questions concerning cardiological problems to be addressed during a PPE.
Table 4. The 14-element ESC (92) and AHA (96) questionnaire for pre-participation cardiovascular screening of competitive athletes.
The use of an electrocardiogram (ECG) is proposed as a screening tool in young athletes to identify potentially life-threatening arrhythmias (e.g., channelopathies, pre-excitation syndromes), structural congenital heart disease, and cardiomyopathies (21, 111). Data relating to the use of ECG during a PPE are controversial especially in the United States (117, 118) but may be required for highly trained athletes by some sports organization. In the absence of clear evidence, the AMSSM respects physician autonomy in implementing an ECG as the most appropriate PPE cardiovascular screening strategy (117). The EFSMA statement from 2015 on ECG for PPE concluded that ECG is very sensitive in heart screening (119). In Italy, cardiovascular PPE protocols including ECG prior to competitive sports practice was adopted by the ESC in 2005 as the “common European protocol” (111) and implemented by many National European Sport Associations during screening of top-level adult athletes (120, 121). In Europe, cardiovascular screening that includes ECG before playing sports in youth is supported by some governing bodies. In selected individual athletes, further non-invasive or invasive cardiac evaluation may be required before the final decision of clearance for participation after the initial cardiovascular PPE (111, 116). In Switzerland, it is recommended that all young athletes practicing with a team with a training load of at least 6 h per week undergo PPCE based on medical history and physical examination from the age of 12 years onward. Inclusion of a standard 12-lead ECG evaluation is also suggested for all post-pubertal athletes (or older than 15 years) with an analysis in accordance with the International Criteria for ECG Interpretation in Athletes (31).
Specific individual history and physical examination forms
Laboratory tests
There are no routine laboratory tests that have been proven to be useful and cost-effective as elements of a PPE (67). Routine laboratory or other tests during the PPE have not been supported by sports medicine societies (67, 122).
The female and male athlete triad syndrome in top-level young athletes
The female athlete triad syndrome with symptoms of amenorrhea, decreased bone mineral density (frequent stress fractures, osteoporosis), and disordered eating may appear in the absence of a balanced diet (123–125). The male athlete triad syndrome occurs most frequently in adolescent and young adult male endurance and weight-class athletes and includes low energy availability with or without disordered eating, functional hypothalamic hypogonadism, and osteoporosis or low bone mineral density (125, 126). In 2014, the International Olympic Committee (IOC) changed the term athlete triad to relative energy deficiency in sports (RED-S) (127). This concept allows identification of energy deficiency as a key to the disruption of several physiological functions of different areas, such as reproduction, bone, endocrine, metabolic, hematological, growth and development, physiological, cardiovascular, gastrointestinal, and immunological, with consequences for the performance and health of the athlete in general (128).
Doping laws
During a PPE, it is necessary to inform a child or adolescent who is eligible for competitive sports that he or she must meet the requirements of doping laws (26, 129, 130). Establishing a Therapeutic Use Exemptions Certificate is therefore mandatory if subjects need to take any of the prohibited substances or medical therapies listed each year by the World Anti-Doping Agency (www.wada-ama.org) (131).
Sport disciplines associated with increased risk of undesirable health consequences
Sports recommendations for young athletes should also be concerned with the particular form of PA. Healthcare providers should recognize individual risks for the pediatric athlete in participating in the sport discipline chosen, because some sport disciplines may have particular constraints and may be subject to specific medical examinations. According to the government regulations in France, sport disciplines with a higher risk of injury for athletes are as follows (130, 132): (1) practiced in a specific environment (mountaineering, underwater diving, caving), (2) competition fighting, in which the fight may end as a result rendering them unconscious and incapable of defending themselves, (3) involving the use of firearms or compressed air, (4) involving the use of motorized land vehicles (except for radio-controlled automobile model making), (5) aeronautical sport disciplines practiced in competition (except for model aircraft), (6) parachuting, and (7) rugby fifteens, rugby thirteen, and rugby sevens.
Some PA might be related to a higher risk of injury if unconsciousness occurs (e.g., in swimming, climbing, or horseback riding), and some other types of PA have a high risk of collision or trauma (e.g., in athletes with implanted electrical cardiological devices or with congenital bleeding disorders who are taking anticoagulants) (19, 24, 28, 133). Sport disciplines have been classified as non-contact, limited contact, or with contact/collision which were described in detail by the AAP (23, 52).
The safe age categories for combat sport disciplines are proposed below with criteria that are considered in the most frequently practiced sport disciplines: (1) participation in boxing for children and youth is not recommend, and (2) children younger than 12 years may participate only in non-contact sports involving training and competition in a form of technique demonstration or directed combat with task performance. They can participate in competition with non-contact activities. In disciplines not involving kicking or hitting, children can participate in training and competition from the age of 9–10 years in accordance with the regulations of sport federations, and (3) youth older than 12 years, who have participated in training and non-contact disciplines for at least 9 months, may participate in classes and training sessions and compete in combat sports with limited contact if the training or competition does not involve fighting using hand or leg blows with full force (25).
In all combat sports that include hitting or kicking, or use of weapons, participants should use protection for the mouth, genitals, breast (girls), and other body parts according to regulations (25). Table 5 contains a list of recommended significant personal history questions to be asked during a PPE before qualification for selected sport disciplines for young athletes associated with increased risk of undesirable health consequences.
Table 5. List of recommended diagnostic examinations during the first pre-participation physical evaluation and repeated every 1–2 years during repetitive control evaluation of young athletes.
Young athlete medical eligibility form
After the results of the PPE are analyzed, athletes will likely be classified according to one of the following (29):
• Medically eligible for sports performance without restriction.
• Medically eligible with recommendation for further management.
• Not medically eligible for sports performance: for all sport disciplines or a selected discipline, temporary or constantly contraindicated.
Healthcare professionals should provide written guidelines with restrictions and permissions regarding adequate levels of PA and exercise. Determination of sports eligibility depends on historical and current examination findings and the sport in which the athlete desires to participate. Fever, acute illness, and viral myocarditis are conditions temporarily limiting sport participation. Limiting activity is also important for preventing complications such as dehydration or thermoregulatory problems. Some athletes will require further re-evaluation (e.g., referral to cardiology, neurology, or orthopedic specialists) (28, 95, 99, 100) and treatment (e.g., treatment of hypertension or exercise-induced bronchospasm, ablation of accessory pathway in WPW syndrome, implantation of cardioverter defibrillator) (28), or they should be included in a physiotherapy program (e.g., after an orthopedic operation) before a return to play (RTP). Participation in PA should be assessed regularly.
Table 6 contains a list of proposed diagnostic examinations during the first PPE which should be repeated every 1–2 years for a repetitive control evaluation of young athletes.
Table 6. List of recommended significant personal history questions during PPE before qualification to selected sport discipline in young athletes with increased risk of undesirable health consequences.
Evaluation for resumption of physical activity/sport activity for a child/adolescent with COVID-19 infection
Serious consideration needs to be given to RTP policies regarding COVID-19 infections in the pediatric and adolescent population. The AAP guidance from 2022 suggested that all eligible participants should receive a primary course of COVID-19 vaccine or booster doses when recommended (135). A history of COVID-19 infection and symptoms should also be included in the PPE (135). Any young athlete who tests positive for current COVID-19 infection, even if asymptomatic, should avoid all training and games until cleared by a physician. Long COVID is diagnosed when symptoms persist for more than 3 months (136). This condition includes many clinical symptoms such as fatigue, breathlessness, brain fog, depression, and inability to return to normal PA. Coronavirus disease has also created a new condition termed pediatric multisystem inflammatory syndrome (PIMS) (137). Multi-organ changes during PIMS can involve the cardiovascular, respiratory, kidney, gastrointestinal, and neurological systems.
The decision to return to PA after COVID-19 should take into account the duration of the disease, the severity of respiratory or cardiac symptoms (138), as well as the presence of comorbidities, and the capacity and the intensity of the planned exercise (139). In 2022, the Scientific Council of the Deutsche Gesellschaft fur Sportmedizin und Pravention (DGSP) published guidelines for returning to sports after COVID-19 that was addressed to elite athletes (140). It recommended limiting PA with a 3-day training pause after the time of diagnosis for an asymptomatic course of COVID-19. Mild competitions may be possible after a total of 10 days have elapsed after the symptoms have disappeared. In a recent document from 2022, the AAP recommends that members of the pediatric population have a minimum of 2-week rest period without exercises (134). Symptomatic patients should limit PA for 2–4 weeks. In Europe, athletes are advised to wait to RTP for a minimum of 10 days from the onset of symptoms, plus a minimum of 7 days from the resolution of COVID-19 symptoms (141). Because of the limited information on COVID-19 and exercise, it is strongly advised that all athletes who have had COVID-19 be cleared for participation by their primary care physician (134). If primary care physicians have any questions regarding their patients’ readiness to return to competition, they should feel free to refer them to a pediatric medical subspecialist. Any child with a history of a positive COVID-19 test, regardless of whether they had symptoms, should be screened for chest pain, shortness of breath, syncope, and palpitations and have a complete physical exam (142, 143). Youth who have had moderate or severe symptoms of COVID-19 should be referred to a cardiologist (144, 145).
Table 7 summarizes sports recommendations based on the severity of symptoms for children and adolescents according to the WHO definitions of COVID-19 infection (146).
Table 7. Recommendations for resumption of physical activity/sport activity based on the severity of symptoms for children and adolescents with COVID-19 infection.
When returning to PA, children and adolescents should gradually increase the frequency, training volume (duration of training session, miles, repetitions), and intensity of activity to avoid injury. Based on an assessment of current and previous activity levels, young athletes should return to activity at 25%–50% of the volume and intensity at which they were participating previously (147). Finally, it is important to consider not only the physical but also the mental wellbeing of athletes before RTP (148). Counseling or psychotherapy should be considered for those having difficulty coping or for those experiencing emotional distress (149).
Sports and exercise medicine
Sport and exercise medicine is a new multidisciplinary medical specialty that supports all subjects and patients who want to engage in PA, exercise, and sports. These medical specialists are also experts regarding the performance of athletes while maintaining their health (57). In Europe, there are countries where SEM is not a medical specialty (150–152). As a result, athletes’ screening programs performed by a pediatrician may differ. Pre-participation physical evaluations certified by SEM are mandatory or strongly recommended mainly for competitive sports (151). In opinion of the EFSMA, it is essential that medical specialists involved in sport and exercise medicine aspire to create a standard of care for athletes at all levels, including a standardized digital PPE among European countries (29, 58).
Summary
Currently, there are no uniform and accepted guidelines for a PPE protocol to be implemented by primary care physicians in Europe for the general pediatric population. The first part of the EAP and the ECPCP position statement presents and summarizes the criteria which are considered to be the most frequently practiced in sports PPE based on expert opinion, reflecting an analysis of the current literature. The aim of this statement is to assist health professionals in implementing the best management programs for sports PPE in individual children and adolescents.
In the absence of a uniform protocol, it is necessary to respect physician autonomy for choosing and implementing the most appropriate and familiar PPE screening strategy and to discuss the decisions made with young athletes and their families (117). This first part of the Position Statement concerning Sport Activities for Children and Adolescents is dedicated to healthy young athletes and does not cover all problems of sport participation in the pediatric population.
EAP and ECPCP statement for pediatrician and primary care pediatricians concerning pre-participation physical evaluation in young athletes: summary
1. The utility of the sports PPE in the healthy population has been questioned in recent years, but the EAP and the ECPCP strongly recommend performing such evaluation in children and adolescents because the main scope of sports PPE is to maximize safe participation in the pediatric population of athletes.
2. In European countries, local and state requirements determine who is authorized to carry out sports PPE: usually these are general practitioners or pediatricians, but in some countries, the determination of sports eligibility depends on the opinion of the sport and exercise medicine specialist, especially for top-level competitive sports.
3. The timing of the sports PPE should be several weeks before a competition in order to incorporate additional examinations or treatment if needed and should be repeated at least every 1–2 years or more frequently depending on government, state, or sport society requirements, in selected type of sports or for selective health problems in athletes, especially in top-level athletes.
4. In the opinion of the EAP and the ECPCP, sports PPE should include diagnostic elements such as health status, anthropometry, functional capacity, and exercise capacity. The PPE history is designed to identify athletes at risk, especially in athletes with a family history of sudden death. Parental verification of individual and family history is recommended. A physical examination should include an evaluation of biological maturation and vital signs such as visual acuity and a cardiovascular, pulmonary, abdominal, skin, genitalia, neurologic, and musculoskeletal assessment.
5. The EAP and the ECPCP recommend educating athletes during the PPE in topics such as injury prevention or concussion, first-aid and external defibrillator–cardioverter support performance, dietary counseling, the effects of nutritional supplements, and doping practices.
6. Because most of the cases of cardiac death in pediatric athletes occur during exercise in individuals with pre-existing cardiac abnormalities, mostly due to inherited or congenital cardiac disorders, the EAP and the ECPCP strongly recommend to apply protocol proposed by the ESC for a cardiovascular PPE of athletes for the prevention of SAD; the so-called “the Lausanne recommendations.”
7. In the opinion of the EAP and the ECPCP, an electrocardiogram is a very sensitive screening tool for young athletes to determine heart disease or cardiomyopathies. According to ESC recommendations, it is recommended to include an ECG in a PPE cardiovascular screening before practicing sports.
8. Healthcare providers should recognize the individual risks of a pediatric athlete participating in a chosen sport discipline because some sport disciplines may have particular constraints and are subject to a specific medical assessment.
9. Young athletes should be classified as (1) medically eligible for sports performance without restriction, (2) medically eligible with recommendation for further evaluation, or (3) under treatment or not medically eligible for sports performance for all sport disciplines or a selected discipline temporary or constantly contraindicated. Young athletes should receive recommendations regarding appropriate levels of PA and exercise.
10. The EAP and the ECPCP encourages collaborative decision-making with the athlete and his or her family or caregiver.
11. Serious consideration needs to be given to return-to-play policies regarding COVID-19 infections in the pediatric and adolescent population. The EAP and the ECPCP strongly recommend that a history of COVID-19 infection and symptoms also be included in the PPE, and any young athlete who tests positive for current COVID-19 infection, even if asymptomatic, should cease all trainings and games until medical approval is obtained.
12. The aim of presented first part of the EAP and the ECPCP position statement is to assist healthcare professionals in implementing the best management strategies for sports pre-participation in individual children and adolescents.
13. In the absence of a uniform sports PPE protocol for children and adolescents in Europe, this EAP and ECPCP statement is not a formal recommendation for PPE, but rather a summary of practical applications and suggestions based on a current narrative review. In the opinion of the EAP and the ECPCP, it is necessary to respect physician autonomy for choosing and implementing the most appropriate and familiar PPE screening strategy and to discuss the decisions made with young athletes and their families.
Author contributions
AT-K and DN: study design. AT-K, JW, and MK-D: data collection. AT-K, DN, TK, AB, MK-D, and AH: data analysis and interpretation. AT-K, DN, and JW: manuscript preparation. AM, ŁD, SdT, ZG, SB, JP-P, and GH: critical revision. All authors contributed to the article and approved the submitted version.
Conflict of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Publisher's note
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Keywords: adolescents, children, physical evaluation, pre-participation, sport, young athlete
Citation: Turska-Kmieć A, Neunhaeuserer D, Mazur A, Dembiński Ł, del Torso S, Grossman Z, Barak S, Hadjipanayis A, Peregud-Pogorzelski J, Kostka T, Bugajski A, Huss G, Kowalczyk-Domagała M and Wyszyńska J (2023) Sport activities for children and adolescents: the Position of the European Academy of Paediatrics and the European Confederation of Primary Care Paediatricians 2023—Part 1. Pre-participation physical evaluation in young athletes. Front. Pediatr. 11:1125958. doi: 10.3389/fped.2023.1125958
Received: 16 December 2022; Accepted: 5 June 2023;
Published: 22 June 2023.
Edited by:
Steven Hirschfeld, Uniformed Services University of the Health Sciences, United StatesReviewed by:
Alan David Rogol, University of Virginia, United StatesDoina Anca Plesca, Carol Davila University of Medicine and Pharmacy, Romania
© 2023 Turska-Kmieć, Neunhaeuserer, Mazur, Dembiński, del Torso, Grossman, Barak, Hadjipanayis, Peregud-Pogorzelski, Kostka, Bugajski, Huss, Kowalczyk-Domagała and Wyszyńska. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Justyna Wyszyńska and5c3p5bnNrYUB1ci5lZHUucGw=
†ORCID Justyna Wyszyńska orcid.org/0000-0002-5786-6214