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Panel endorses preparticipation sports physicals for every child
Cardiac health problems received more attention in updated edition.
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The fourth edition Preparticipation Physical Evaluation (PPE) monograph will feature “huge changes,” including recommending preparticipation screening for all youth – not just those who are playing competitive sports, and a revamped health questionnaire that will focus on cardiac health problems.
Cindy J. Chang, MD, who is a member of the monograph writing group and assistant clinical professor at the University of California, San Francisco, told Cardiology Today that although the authors acknowledge that immunizations and sick visits are likely to consume most of a pediatrician’s time, it is their goal that recommending PPEs for all children would provide an additional opportunity for a well-child examination.
“Our goal in performing a PPE is not to exclude anyone from participation but to promote the health and safety of the athlete for training and competition,” Chang said. “Even if children aren’t trying out for a sport at their middle school or high school, the emphasis should be on promoting health and fitness for all kids.”
Teri M. McCambridge, MD, an assistant professor of pediatrics at Johns Hopkins University School of Medicine in Baltimore, said there is an added benefit to a regular well-child PPE.
“The [primary care physician] knows the athlete and family the best,” McCambridge said. “One of the problems that you run into doing these screening exams [as a team physician] is that you’re seeing a piece of paper that a child has filled out. Additionally, especially for college students, they may not have filled it out honestly because they’re afraid that it might put their scholarship at stake. But if you’re the primary care physician, you know that history or have access to that history and can address it.”
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Photo by: Kathleen Ferris
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New science, sweeping changes
The shift in recommending PPEs for all children is just one facet of the “sweeping, huge changes” based on more current scientific data, said William O. Roberts, MD, a professor of medicine at the University of Minnesota Medical School and director of St. John’s Hospital family medicine residency program in St. Paul.
For years, PPEs have been required from middle school through college for those who wanted to play school sports. Physicians assessed a student’s health and granted approval for athletic participation by signing a clearance form. Before the initial monograph’s inception, however, no specific recommendations existed to guide physicians in their examinations. Consequently, they became uneasy with the quality of care that children were receiving, Roberts said in an interview.
Even now, PPEs remain inconsistent because clearance forms, which differ from state to state, dictate the way that a PPE is conducted.
“Some states still use a sheet of paper that says, ‘Johnny can play.’ That’s what I grew up with, and we’re really trying to move states away from that to a standardized set of questions that might help people around the country,” Roberts said. “Our goal is to get some facsimile of the questionnaire used in every state for middle schools, high schools, colleges and, if possible, youth programs around the country.”
Past and present versions of the PPE consist of a physical examination component and a questionnaire designed to identify risk factors and predictors of potentially dangerous underlying conditions.
David T. Bernhardt, MD, a professor in the departments of pediatrics, orthopedics and rehabilitation and sports medicine at the University of Wisconsin School of Medicine and Public Health in Madison, said the writing group revamped the questionnaire to hone in on certain cardiac health problems that may be exacerbated by physical activity.
“The newer questions target some extremely rare heart conditions, such as hypertrophic cardiomyopathy and ion channelopathies, that are more likely to lead to sudden deaths while somebody is exerting himself,” Bernhardt said in an interview with Cardiology Today.
“We’re going to ask questions such as, ‘Has anyone in your family died of sudden infant death syndrome?’ or ‘Have you or has anybody in your family had an unexplained seizure?’ These [health issues] could be indicators of one of these undefined channelopathies,” he said.
The questionnaire now also surveys whether there is a family history of any unexplained drowning or unwitnessed car accidents because research has linked these incidents with undiagnosed heart conditions.
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Roberts said the fourth edition of the PPE monograph contains a supplemental education section that will help parents and children better understand the questions and underscore the importance of answering them honestly and correctly.
“The (newest version of the) monograph is almost double the number of pages of the previous edition because we’re trying to explain why there are so many questions,” Roberts said. “We say, ‘These are important questions about your heart,’ and ‘These are important heart questions about your family,’ to try to emphasize what answering these questions has to do with cardiac status and get people to focus on them.”
ECG controversy
Although the new recommendations hone in on those children who may be most susceptible to cardiac problems during physical activity, the monograph takes a firm stance on the routine use of electrocardiogram tests, calling the practice “impractical.”
The International Olympic Committee and the European Society of Cardiology endorse routine ECGs for young competitive athletes. Those European recommendations followed a study from Italy, in which all young athletes were required to get an ECG before participation. The Italians reported an 89% decrease in sudden cardiac death after implementation of that program.
The question of routine ECGs was a controversial issue among the monograph writers, (See perspectives for more), but Chang said the writers opted not to recommend routine ECGs because “if we mandate screening for everyone, we will lose young kids who can’t afford it or who don’t have access to those services. I’m not against it, but I don’t think it should be mandatory.”
Looking ahead
Another facet of PPEs that is addressed in the monograph is the electronic preparticipation physical evaluation (ePPE).
“It’s an electronic version of the history form that children can fill out at home with their parents’ help that has all the branching questions. … You finish it, print it out and bring it to your doctor, and he’s got that focused history all done,” Roberts said.
Unlike the current form that contains 50 questions, the ePPE can include up to 1,500 questions, depending on the child’s answers. If a child answers “yes” to a question that may indicate a serious health problem, the electronic form branches to include more specific questions, so as to better identify the potential issue.
Roberts said the ePPE may eliminate difficulties with getting parents and children to fill out such a long questionnaire in the waiting room. By answering at home on a computer at the patient’s convenience, the child and parents may be willing to spend more time on the questions, arming their physician with more thorough information for their visit. – by Melissa Foster
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The panel agreed that routine use of ECGs is likely not feasible at this time. College and professional teams usually have more financial resources and may be able to incorporate additional testing, whereas middle school and high school athletic departments generally do not have the funds to support regular ECG screening.
Also, there is a potential for false positive results if those reading ECGs are not experienced or are not using the appropriate criteria.
– Jonathan Drezner, MD
Associate Professor of Family Medicine
University of
Washington, Seattle
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There is enough reason and evidence to support ECG testing in young adults. The Italian data showed that
supplementing the standard history and physical with ECG screening in young athletes can have a significant impact on detecting and reducing the sudden deaths that occur as a result of serious, underlying cardiac conditions. Research conducted by Atkins et al in 11 Canadian and U.S. cities indicated a high sudden cardiac death rate in young adults. If one extrapolated from the incidence that they found in their population, physicians could expect anywhere between 2,000 and 3,000 deaths per year.
These findings are important because people arguing against ECG testing for young adults cite lower incidence of sudden cardiac death in the United States when compared with the Italian data, but that is not the case.
Research highlighting high false positive rates also inspires hesitancy about using ECG testing, but those studies employed an exceptionally narrow margin and identified many minor aberrations as abnormal. Furthermore, ECG screening should extend beyond athletes to all young adults.
– Joseph Marek, MD
Cardiologist and Internal Medicine Specialist
Downers
Grove, Ill.