“A high school lacrosse player collapsed yesterday during practice and later died. The player, 15, had no known medical problems and was just a week shy of his 16th birthday when he collapsed on the playing field at…”

It’s an unexpected tragedy, but we have all heard about such youth sport tragedies. All too often, the cause of death turns out to be a previously undetected congenital problem in the heart’s structural or electrical system. It comes as a shock because we think of our active youth as the most healthy of kids.

Youth sports does help children improve physical coordination, boost self- esteem, maintain physical fitness, foster self-discipline, and provide a healthy social and personal development, but it may also expose our children to unnecessary risk.

In April, Time magazine reported that 40 million American youths between the ages of 6 and 18 participated in various organized sports. To be sure, all of those practices, games, and competitions keep our kids active and put them to the test. They keep us parents on our toes too. But as we outfit our kids with the best helmets and pads, and educate them about safety on the field and in the bus on the way to competition, how well do we know if their bodies are able to stand up to the rigors of the field?

In the US, 1 out of every 100,000 children dies because of sudden death caused by silent conditions, primarily, according to research, cardiovascular diseases predominantly consisting of cardiomyopathies, premature coronary artery disease, and congenital coronary anomalies. When you talk about just children involved in sports and leave out sedentary kids, that number almost triples (to 2.5 to 3 out of 100,000). You cannot say sports increase the chance of sudden death because no one knows the overall long-term benefit of sports participation; furthermore, sports amplify the impact of silent problems--they don’t cause them. Unfortunately, with many of these risk factors, people often have no symptoms; they feel well. The first symptom of some risk factors can be sudden death.

In the US, most youth participants in team sports are required to have a physician’s signature in order to play; the standard of care is that these athletes have a preparticipation sports examination (PSE) before the season begins. All but one state (Rhode Island) require a PSE before sports participation. The primary goal of the PSE is to maximize safe participation by children and adolescents. For most kids, this means their doctor will give them a 15-minute in-office physical that includes taking their blood pressure and listening to their heart. However, many parents are only too willing to have the doctor simply fill out the PSE slip based on previous exams and leave it with the receptionist without ever seeing the child for this specific reason.

In other countries, this is not the case. A nationwide systematic preparticipation athletic screening was introduced in Italy in 1982, for example, requiring a complete personal and family history, physical examination with blood pressure measurement, a lung function test (to screen for asthma), a urine test, and a 12-lead ECG, resting and after a three-minute step test. These tests have been proven to help pinpoint silent factors that are of highest risk to young athletes on the playing field. The 12-lead ECG, in particular, offers the potential to detect potentially lethal conditions, including other myocardial diseases, dilated cardiomyopathy, myocarditis, long QT syndrome, Lenègre disease, Brugada syndrome, cathecolaminergic ventricular tachycardia, short QT syndrome, and Wolff-Parkinson-White (WPW) syndrome. Based on published series from the US and Italy, these conditions, including hypertrophic cardiomyopathy, account for up to 60 percent of sudden deaths in young competitive athletes.

Our more lax PSE requirements are the result of a report issued over ten years ago, titled “Cardiovascular Preparticipation Screening of Competitive Athletes,” published in Circulation, a journal of the American Heart Association, and endorsed by the American Academy of Pediatrics Section on Cardiology. Interesting to note that this report also includes a look at the “cost-efficiency and feasibility issues as well as the medical and legal implications of screening.” In other words: Sure, we’re going to save a few kids–but what’s it going to cost? The University of Nevada, Reno checked into that and, in a study, showed these tests would cost US insurance companies $20,000 for every child athlete whose life was saved.

In Italy, the costs are kept low, about $40 altogether, and the government covers it for all people under 18. All kids who participate in sports are required to have it at age 12. In the US, however, insurance companies have determined that such screening is too costly and sports governing bodies fear testing would raise their liability. In Italy, the belief is that all young competitive athletes are worth screening. (Young competitive athletes are defined as people 35 years or younger, who are regularly engaged in exercise training, and who participate in official athletic competitions. Characteristics of competitive athletes are their strong inclination to extend themselves to their physical limits and to improve performance.)

A study published in JAMA last year showed that the annual incidence of sudden cardiovascular death in young competitive athletes in Italy has decreased by 89 percent since the introduction of nationwide systematic screening. The European Society of Cardiology (ESC) subsequently got onboard with a statement published in the European Heart Journal, recommending that every young competitive athlete undergo cardiovascular screening. As in the US, the ESC recommended protocol calls for a complete physical examination and personal and family medical history. However, the ESC also mandates a 12-lead electrocardiogram (ECG), which is not yet required in the US. Lead author Domenico Corrado suggests that including the ECG in cardiovascular screening may decrease sports-related cardiac deaths in Europe by 50 percent to 70 percent if implemented in every European country. These tests have the side benefit of giving young athletes a physiologic profile with which they can direct their training.

It seems reasonable—and, okay, ethically and clinically justifiable—that we should make every effort to recognize the risk of such silent problems so affected kids can be disqualified in order to prevent athletic field death. A screening protocol that includes an ECG alone would reduce the risk of sudden death in athletes. The screening of US high-school and college athletes, based on medical history and physical examination without ECG, was shown to be lacking in identifying cardiovascular abnormalities and increasing risk of sudden death. In a US retrospective study, only 3 percent of trained athletes who died suddenly of heart disease had been suspected of having cardiovascular abnormalities on the basis of preparticipation screening. By comparison, screening with ECG in Italy was able to identify asymptomatic cardiovascular disease in athletes, and long-term follow-up suggests withdrawal from competition may improve survival rates. If you look closely at the Italian studies, it shows that less than one quarter of young competitive athletes diagnosed with certain cardiovascular diseases had had a positive family history or an abnormal physical examination. Thus, the majority of them would have not been identified by a screening protocol that didn’t include a 12-lead ECG, yet 80 percent of athletes who died from certain cardiac diseases had ECG changes and/or ventricular arrhythmias that would have shown up on a 12-lead ECG.

The threefold greater number of athletes who were afflicted with silent conditions that were identified by the Italian screening and disqualified from competitive sports means three times more lives saved compared with the American Heart Association strategy. The 12-lead ECG also offers the potential to identify asymptomatic athletes with other conditions that show up as ECG abnormalities, a number of which have been discovered only recently, so that diagnosis at preparticipation screening will likely increase over time.

If you have a child playing a competitive sport, don’t panic and throw the hockey stick and dance shoes in the dumpster. But do talk to your pediatrician to be sure your child gets a thorough cardiovascular screening. Also, talk to your parents and relatives and find out about any heart conditions in relatives, particularly heart attacks at young ages. The more information we have, the better prepared we can be.

In a larger sense, we have to ask ourselves: Are we doing enough to screen kids who are participating in rigorous youth sports? What level of sports clearance physical exam should we be demanding? As parents, perhaps we need to go into a huddle and devise a play that pushes through cost and liability concerns of insurance companies to allow our pediatricians, our sports governing bodies, and our lawmakers to ensure our children—and their teammates—get the necessary cardiovascular screening.

DeAnne Musolf
is the editor-in-chief of Active Cities magazine and a  columnist who writes frequently on
children and activity. She can be reached at deanneACUSA@aol.com

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