OFFICIAL ABP TOPIC:

Understand return to activity criteria following an illness and advise patients appropriately

BACKGROUND

Returning to mental or physical activity too soon after an illness risks worsening the condition or causing new complications, while overly restricting activities can negatively impact the child’s physical, social, and emotional well-being. Pediatricians must balance these considerations, using their clinical judgment and the best available evidence, to guide patients and families through the recovery process.

GENERAL PRINCIPLES

• Resolution of symptoms: In most cases, a child should be symptom-free or have significant improvement in symptoms before returning to normal activities. This usually includes no fever for the past 24 hours. Persisting symptoms often indicate that the body still requires rest to facilitate recovery.
• Tolerance of daily activities: Children should be able to perform basic self-care and engage in low-level physical and cognitive activities without a recurrence or worsening of symptoms. This indicates readiness for increased demands.
• Discontinuation of symptom-controlling medications: Children should be able to discontinue or significantly reduce use of any medications prescribed to control symptoms before fully returning to activities.
• Gradual resumption of activities: Mental and physical activities should usually be increased gradually, limiting strenuous activities while staying active within comfort levels. If symptoms return, decrease activity to the previously tolerated level.

CONDITION-SPECIFIC GUIDANCE

CONCUSSION

Concussions warrant a cautious approach to resuming activities due to the risk of prolonged symptoms and serious complications like second impact syndrome. Current guidelines recommend a stepwise return to both mental and physical activities.

Return to Learn
Returning to school should not occur until the child can tolerate 30–45 minutes of cognitive activity without worsening symptoms. A gradual return with decreasing accommodations can then begin.

Children with concussions should remain symptom-free for at least 24 hours at each stage before progressing to the next. If symptoms recur, returning to the previous stage is advised until symptoms resolve.

Return to Play
Progressing back to sports should only occur after successfully returning to school. A stepwise increase in physical exertion should be guided by symptoms.

To receive final clearance for contact sports after a concussion, the child must be symptom-free both at rest and with exertion, off all medications, back to their academic baseline, and have a normal neurological exam. The process should take a minimum of 7–10 days but may require longer for some children.

INFECTIOUS MONONUCLEOSIS

Mononucleosis often requires an extended recovery period due to prolonged fatigue and the risk of splenic rupture.

• The child must be afebrile and have no ongoing throat symptoms before returning to activities.
• Light to moderate aerobic activity can often begin 3 weeks after symptom onset.
• Strenuous contact sports can be restarted 4 weeks after symptom onset if spleen size is normal since the risk of splenic rupture is highest in the first month.
• Fatigue may sometimes persist for months. Children should restart activities slowly and increase them gradually as tolerated.

COVID-19

The long-term impacts of COVID-19 are still being studied, but emerging evidence suggests risks for myocarditis or prolonged symptoms in some children.

• Children with asymptomatic or mild COVID-19 may return to normal activity as tolerated after 5 days of isolation and no fever for at least 24 hours.
• Children with moderate COVID-19 (at least 4 days of fever and one week of myalgia, chills, or lethargy) should not exercise until they are evaluated by their PCP. They may return to sports at least 10 days after symptom onset if they are cleared by their PCP with a negative screen for cardiac symptoms (e.g., chest pain, shortness of breath, palpitations, syncope) and a normal EKG.
• Children with severe COVID-19 (ICU stay, intubation, MIS-C) should be restricted from exercise for 3-6 months and obtain cardiology clearance before returning to sports.

OTHER RESPIRATORY ILLNESSES

Children with common respiratory illnesses should progress activity gradually based on symptom resolution and improving stamina.

• Colds/URI: Return to school when fever-free >24 hours and symptoms are manageable.
• Bronchiolitis: Typically 2–3 days off school until fever resolves and respiratory distress improves.
• Pneumonia: Usually 3–5 days off school; return when fever-free and energy is improving. Generally, children should wait 1-2 weeks before returning to sports.

REFERENCES

https://www.uptodate.com/contents/concussion-in-children-and-adolescents-management

https://www.uptodate.com/contents/covid-19-return-to-sport-or-strenuous-activity-following-infection

https://www.uptodate.com/contents/infectious-mononucleosis

https://www.cdc.gov/respiratory-viruses/prevention/precautions-when-sick.html

https://www.cdc.gov/disasters-and-children/php/interventions/when-students-or-staff-are-sick.html

https://www.cdc.gov/orr/school-preparedness/infection-prevention/docs/IPC-Science-Brief_508.pdf