PEDIATRICS Vol. 107 No. 5 May 2001, pp. 1205-1209

AMERICAN ACADEMY OF PEDIATRICS:
Medical Conditions Affecting Sports Participation

Committee on Sports Medicine and Fitness

	ABSTRACT

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Children and adolescents with medical conditions present special issues with respect to participation in athletic activities. The pediatrician can play an important role in determining whether a child with a health condition should participate in certain sports by assessing the child's health status, suggesting appropriate equipment or modifications of sports to decrease the risk of injury, and educating the athlete and parents on the risks of injury as they relate to the child's condition. This statement updates a previous policy statement and provides information for pediatricians on sports participation for children and adolescents with medical conditions.

	INTRODUCTION

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In 1994, the American Academy of Pediatrics published an analysis of medical conditions affecting sports participation.¹ This statement replaces the previous version and provides additions and changes to increase the accuracy and completeness of the information.

Sports are categorized by their probability for collision or contact in Table 1. In "collision" sports (eg, boxing, ice hockey, football, and rodeo), athletes purposely hit or collide with each other or inanimate objects, including the ground, with great force. In "contact" sports (eg, basketball and soccer), athletes routinely make contact with each other or inanimate objects but usually with less force than in collision sports. Table 1 does not separate collision and contact sports, because there is no clear dividing line between them. In "limited-contact" sports (eg, softball and squash), contact with other athletes or inanimate objects is infrequent or inadvertent.

Some limited-contact sports (eg, downhill skiing and gymnastics) can be as dangerous as contact or collision sports. Even in noncontact sports, such as power lifting, serious injuries can occur. Overuse injuries are not related to contact or collision. For these reasons, the categorization of sports in Table 1 insufficiently reflects the relative risks of injury.¹ The categorization, however, gives an idea of the comparative likelihood that participation in different sports will result in acute traumatic injuries resulting from blows to the body.

The medical conditions listed in Table 2 have been assessed to determine if participation would create an increased risk of injury or adversely affect the medical condition. Table 2 is valuable when a physician examines an athlete who has 1 of the listed problems. Decisions about sports participation are often complex, and the usefulness of Table 2 is limited by the frequency with which it recommends individual assessment when a "qualified yes" or a "qualified no" appears. For the majority of chronic health conditions, however, current evidence supports the participation of children and adolescents in most athletic activities.

The physician's clinical judgment is essential for applying these recommendations to a specific patient. This judgment involves the available published information on the risks of participation, the advice of knowledgeable experts, the current health status of the athlete, the level of competition, the position played, the sport in which the athlete participates, the maturity of the competitor, the availability of effective protective equipment that is acceptable to the athlete, the availability and efficacy of treatment, whether treatment (eg, rehabilitation of an injury) has been completed, whether the sport can be modified to allow safer participation, and the ability of the athlete and parents to understand and accept risks involved in participation. Potential dangers of associated training activities should also be considered. For example, strength training is now a part of conditioning for many sports.

Unfortunately, adequate data on the risks of a particular sport for an athlete with a medical problem often are limited or lacking, and an estimate of risk becomes a necessary part of decision-making. If restriction from a sport is believed necessary, the physician should counsel the athlete and family about safe alternative activities.

The strenuousness of a sport is an additional characteristic relevant to athletes with cardiovascular or pulmonary disease. A strenuous sport can place dynamic (volume) and static (pressure) demands on the cardiovascular system. These demands vary not only with activities of the sport but also with such factors as the associated training activities and the level of emotional arousal and fitness of the competitors. Table 3 lists sports by their strenuousness as classified by experts. The authors of Table 3 state that the classification "may be of theoretical interest, but its practical value is unknown because our current knowledge regarding the relative risks of these 2 types of exercise (dynamic and static) for various cardiovascular abnormalities is limited."⁴

Physicians making decisions about sports participation for patients who have more than mild congenital heart disease or who have cardiac dysrhythmias are encouraged to consider consulting a cardiologist and to review recommendations from the 26th Bethesda Conference.⁴ Information on sports participation for patients with hypertension also is available, indicating that primary hypertension must be severe before exclusion from sports is indicated.^3,12

In recent legal decisions, athletes have been permitted to participate in sports despite known medical risks.¹ When an athlete's family disregards medical advice against participation, the physician should ask all parents or guardians to sign a written informed consent statement indicating that they have been advised of the potential dangers of participation and that they understand them. The physician should also document, with the child's signature, that the child athlete also understands the risks of participation.

Information on the impact of medical problems on the risk of injury during sports participation is available in Care of the Young Athlete by the American Academy of Orthopaedic Surgeons and the American Academy of Pediatrics.¹³ Other policy statements include relevant material.^14-22

Committee on Sports Medicine and Fitness, 2000-2001

Reginald L. Washington, MD, Chairperson

David T. Bernhardt, MD

Jorge Gomez, MD

Miriam D. Johnson, MD

Thomas J. Martin, MD

Thomas W. Rowland, MD

Eric Small, MD

Liaisons

Carl Krein, ATC, PT

National Athletic Trainers Association

Claire LeBlanc, MD

Canadian Paediatric Society

Judith C. Young, PhD

National Association for Sport and Physical Education

Section Liaison

Frederick E. Reed, MD

Section on Orthopaedics

Consultants

Steven J. Anderson, MD

Bernard A. Griesemer, MD

Larry G. McLain, MD

Staff

Heather Newland

	FOOTNOTES

The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

	REFERENCES

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1. American Academy of Pediatrics, Committee on Sports Medicine and Fitness Medical conditions affecting sports participation. Pediatrics 1994; 94:757-760 [Abstract/Free Full Text]
2. American Academy of Pediatrics, Committee on Sports Medicine and Fitness Safety in youth ice hockey: the effects of body checking. Pediatrics 2000; 105:657-658 [Abstract/Free Full Text]
3. National High Blood Pressure Education Program, Working Group on Hypertension Control in Children and Adolescents Update on the 1987 Task Force Report on High Blood Pressure in Children and Adolescents: a working group report from the National High Blood Pressure Education Program. Pediatrics 1996; 98:649-658 [Abstract/Free Full Text]
4. 26th Bethesda Conference: recommendations for determining eligibility for competition in athletes with cardiovascular abnormalities. J Am Coll Cardiol. 1994;24:845-899
5. American Academy of Pediatrics, Committee on Sports Medicine and Fitness Mitral valve prolapse and athletic participation in children and adolescents. Pediatrics 1995; 95:789-790 [Abstract/Free Full Text]
6. Dorsen PJ. Should athletes with one eye, kidney, or testicle play contact sports? Phys Sportsmed. 1986;14:130-133, 137-138
7. American Academy of Pediatrics, Committee on Sports Medicine and Fitness and American Academy of Ophthalmology, Committee on Eye Safety and Sports Ophthalmology Protective eyewear for young athletes. Pediatrics 1996; 98:311-313 [Abstract/Free Full Text]
8. American Medical Society for Sports Medicine and American Academy of Sports Medicine Human immunodeficiency virus and other blood-borne pathogens in sports. Clin J Sports Med 1995; 5:199-204 [Medline]
9. Wojtys EM, Hovda D, Landry G, Concussion in sports. Am J Sports Med 1999; 27:676-687 [Abstract/Free Full Text]
10. Colorado Medical Society, Sports Medicine Committee. Guidelines for the Management of Concussion in Sports, Revised. Denver, CO: Colorado Medical Society; 1991
11. Kerle KK, Runkle GP Sickle cell trait and sudden death in athletes [letter]. JAMA 1996; 276:1472 [Abstract/Free Full Text]
12. American Academy of Pediatrics, Committee on Sports Medicine and Fitness Athletic participation by children and adolescents who have systemic hypertension. Pediatrics 1997; 99:637-638 [Abstract/Free Full Text]
13. American Academy of Orthopaedic Surgeons and American Academy of Pediatrics. In: Sullivan JA, Anderson SJ, eds. Care of the Young Athlete. Elk Grove Village, IL: American Academy of Pediatrics; 2000
14. American Academy of Pediatrics, Committee on Sports Medicine and Fitness Cardiac dysrhythmias and sports. Pediatrics 1995; 95:786-788 [Abstract/Free Full Text]
15. American Academy of Pediatrics, Committee on Sports Medicine and Fitness Horseback riding and head injuries. Pediatrics 1992; 89:512 [Abstract/Free Full Text]
16. American Academy of Pediatrics, Committee on Sports Medicine and Fitness Risk of injury from baseball and softball in children 5 to 14 years of age. Pediatrics 1994; 93:690-692 [Abstract/Free Full Text]
17. American Academy of Pediatrics, Committee on School Health Organized athletics for preadolescent children. Pediatrics 1989; 84:583-584 [Abstract/Free Full Text]
18. American Academy of Pediatrics, Committee on Sports Medicine and Fitness Metered-dose inhaler for young athletes with exercise-induced asthma. Pediatrics 1994; 94:129-130 [Abstract/Free Full Text]
19. American Academy of Pediatrics Human immunodeficiency virus (acquired immunodeficiency syndrome [AIDS] virus) in the athletic setting. Pediatrics 1991; 88:640-641 [Abstract/Free Full Text]
20. American Academy of Pediatrics, Committee on Sports Medicine and Fitness Promotion of healthy weight-control practices in young athletes. Pediatrics 1996; 97:752-753 [Abstract/Free Full Text]
21. American Academy of Pediatrics, Committee on Sports Medicine and Fitness Strength training, weight and power lifting, and body building by children and adolescents. Pediatrics 1990; 86:801-803 [Abstract/Free Full Text]
22. American Academy of Pediatrics, Committee on Sports Medicine and Fitness Fitness, activity, and sports participation in the preschool child. Pediatrics 1992; 90:1002-1004 [Abstract/Free Full Text]