Published online April 1, 2008
PEDIATRICS Vol. 121 No. 4 April 2008, pp. 841-848 (doi:10.1542/peds.2008-0080)
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CLINICAL REPORT

Medical Conditions Affecting Sports Participation

Stephen G. Rice, MD, PhD, MPH and the Council on Sports Medicine and Fitness


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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, parent(s) or guardian, and coach regarding the risks of injury as they relate to the child's condition. This report updates a previous policy statement and provides information for pediatricians on sports participation for children and adolescents with medical conditions.

Key Words: youth • athletes • risk of injury • contact and collision sports • prevention management • strenuousness • safety

In 2001, the American Academy of Pediatrics published an analysis of medical conditions affecting sports participation.1 This updated report replaces the 2001 policy statement and provides additions and changes to increase the accuracy and completeness of the information.

Health care professionals must determine whether a child with a health condition should participate in a particular sport. One way of determining this is by estimating the relative risk of an acute injury to the athlete by categorizing sports as contact, limited-contact, or noncontact sports (Table 1). This categorization may subdivide contact sports into collision and contact sports; although there may be no clear dividing line between the 2, collision implies greater injury risk. In collision sports (eg, boxing, ice hockey, football, lacrosse, and rodeo), athletes purposely hit or collide with each other or with inanimate objects (including the ground) with great force. In contact sports (eg, basketball and soccer), athletes routinely make contact with each other or with inanimate objects but usually with less force than in collision sports. In limited-contact sports (eg, softball and squash), contact with other athletes or with inanimate objects is infrequent or inadvertent. However, some limited-contact sports (eg, skateboarding) can be as dangerous as collision or contact sports. Even in noncontact sports (eg, power lifting), in which contact is rare and unexpected, serious injuries can occur.


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  		TABLE 1 Classification of Sports According to Contact

 
Overuse injuries are related not to contact or collision but to repetitive microtrauma; furthermore, overuse injuries generally are not acute. For these reasons, the categorization of sports in Table 1 insufficiently reflects the relative risks of injury. However, the categorization indicates the comparative likelihood that participation in different sports will result in acute traumatic injuries from blows to the body.

For most chronic health conditions, current evidence supports and encourages the participation of children and adolescents in most athletic activities. However, the medical conditions listed in Table 2 have been assessed to determine whether participation would create an increased risk of injury or affect the child's medical condition adversely. These guidelines can be valuable when a physician examines an athlete who has one 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.


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  		TABLE 2 Medical Conditions and Sports Participation

 
The physician's clinical judgment is essential in the application of these recommendations to a specific patient. This judgment is enhanced by consideration of the available published information on the risks of participation, the risk of acquiring a disease as a result of participation in the sport, and the severity of that disease. Other variables to consider include (1) the advice of knowledgeable experts, (2) the current health status of the athlete, (3) the sport in which the athlete participates, (4) the position played, (5) the level of competition, (6) the maturity of the competitor, (7) the relative size of the athlete (for collision/contact sports), (8) the availability of effective protective equipment that is acceptable to the athlete and/or sport governing body, (9) the availability and efficacy of treatment, (10) whether treatment (eg, rehabilitation of an injury) has been completed, (11) whether the sport can be modified to allow safer participation, and (12) the ability of the athlete's parent(s) or guardian and coach to understand and to accept the risks involved in participation. Potential dangers of associated training activities that lead to repetitive and/or excessive overload also should be considered.

Unfortunately, adequate data on the risks of a particular sport for athletes with medical problems often are limited or lacking, and an estimate of risk becomes a necessary part of the decision-making process. If primary care physicians are uncertain or uncomfortable with the evaluation and/or the decision-making process, they should seek the counsel of a sports medicine specialist or a specialist in the specific area of medical concern. If the physician thinks that restriction from a sport is necessary for a particular patient, then he or she should counsel the athlete and family about safe alternative activities.

Physicians making decisions about sports participation for athletes with cardiovascular disease (Table 2) are strongly encouraged to consider consulting a cardiologist and to review carefully recommendations from the 36th Bethesda Conference.12 The complexities and nuances of cardiovascular disease make it difficult to provide important detailed information in a single table.

An athlete's underlying cardiac pathologic condition and the stress that a sport places on that condition are the 2 primary factors determining the risk of participating in that sport. 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 factors such as the associated training activities and the environment, as well as the level of emotional arousal and fitness of the competitors. Figure 1 lists sports according to their dynamic and static demands, as classified by cardiopulmonary experts of the 36th Bethesda Conference.12


Figure 1
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  		FIGURE 1 Classification of sports according to cardiovascular demands (based on combined static and dynamic components).12 This classification is based on peak static and dynamic components achieved during competition. It should be noted, however, that the higher values may be reached during training. The increasing dynamic component is defined in terms of the estimated percentage of maximal oxygen uptake (Max O2) achieved and results in increasing cardiac output. The increasing static component is related to the estimated percentage of maximal voluntary contraction (MVC) reached and results in increasing blood pressure load. Activities with the lowest total cardiovascular demands (cardiac output and blood pressure) are shown in box IA, and those with the highest demands are shown in box IIIC. Boxes IIA and IB depict activities with low/moderate total cardiovascular demands, boxes IIIA, IIB, and IC depict activities with moderate total cardiovascular demands, and boxes IIIB and IIC depict high/moderate total cardiovascular demands. These categories progress diagonally across the graph from lower left to upper right. a Danger of bodily collision. b Increased risk if syncope occurs. c Participation is not recommended by the American Academy of Pediatrics.2 d The American Academy of Pediatrics classifies cricket in the IB box (low static component and moderate dynamic component).58 (Reproduced with permission from Mitchell JH, Haskell W, Snell P, Van Camp SP. 36th Bethesda Conference. Task force 8: classification of sports. J Am Coll Cardiol. 2005;45(8):1364–1367.)

 
New recommendations on sports participation for athletes with hypertension (Table 2) are available.10,12 The latest blood pressure tables provide the 50th, 90th, 95th, and 99th percentiles based on age, gender, and height.10 The blood pressure reading must be at least 5 mmHg above the 99th percentile before any exclusion from sports is indicated.10 Periodic monitoring of resting (preexercise) blood pressure levels is preferred for readings above the 90th percentile. A more-complete evaluation is performed for sustained blood pressure readings above the 95th percentile.10,12

In earlier legal decisions, athletes have been permitted to participate in sports despite known medical risks and against medical advice, usually in cases involving missing or nonfunctioning paired organs. In recent years, however, courts have been reluctant to permit athletes to participate in competitive athletics contrary to the team physician's medical recommendation. When an athlete's family seeks to disregard such 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 these dangers. The physician should document, with the athlete's signature, that the child or adolescent athlete also understands the risks of participation. To ensure that parents or guardians truly understand the risks and dangers of participation against medical advice, it is recommended that these adults write the statement in their own words and handwriting.59–62

Additional information on the effects 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 Pediatrics63 and Preparticipation Physical Evaluation, Third Edition, by the American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine.7 In addition, other American Academy of Pediatrics policy statements include relevant material.64–67


   COUNCIL ON SPORTS MEDICINE AND FITNESS, EXECUTIVE COMMITTEE, 2006–2007
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Eric W. Small, MD, Chairperson

Teri M. McCambridge, MD, Chairperson-elect

Holly Benjamin, MD

David T. Bernhardt, MD

Joel S. Brenner, MD, MPH

Charles Cappetta, MD

Joseph A. Congeni, MD

Andrew J. Gregory, MD

Bernard A. Griesemer, MD

Frederick E. Reed, MD

Stephen G. Rice, MD, PhD, MPH


   PAST MEMBERS
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Jorge E. Gomez, MD

Douglas B. Gregory, MD

Paul R. Stricker, MD


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Claire Marie Ann LeBlanc, MD

Canadian Paediatric Society

James Raynor, MS, ATC

National Athletic Trainers Association


   CONSULTANT
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Michael F. Bergeron, PhD


   STAFF
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Anjie Emanuel, MPH

Jeanne Lindros, MPH


   FOOTNOTES
 
All clinical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaf.rmed, revised, or retired at or before that time.

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


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PEDIATRICS (ISSN 1098-4275). ©2008 by the American Academy of Pediatrics

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The following policy statement has been revised:

Medical Conditions Affecting Sports Participation

Pediatrics 107: 1205-1209. [Full Text]



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