Sunny-Side-Up Pediatric Sports Cardiology

Sports Cardiology:

Muscular fitness is vital as it significantly contributes to improved overall health via the mechanism of increasing fat-free mass (lean muscle mass), increased metabolic rate, healthy maintenaince of bone mass, improved cardiovascular fitness, increased insulin sensitivity / improved blood glucose and improved overall fitness for the performance of activities of the daily living (e.g., carrying groceries / schoolbags, stairs-climbing). Hence, muscular fitness is an important component of health-related fitness.

Clinical Pediatric Sports Cardiology:
Congenital Heart Defects in Loeys-Dietz Syndrome

Loeys-Dietz Syndrome is a genectic connective tissue disorder with a wide spectrum of multisystem involvement. Loeys-Dietz Syndrome and other aortopathies (e.g., Marfan Syndrome) have overlapping clinical features. Loeys-Dietz Syndrome is characterized by rapidly progressive aortic enlargement and weakened blood vessels. Hence, children with Loeys-Dietz Syndrome are susceptible to aortic dissection and aneurysms throughout the arterial tree. Children with Loeys-Dietz Syndrome also have cranosynostosis, cleft palate, clubfoot, pes planus (flat foot), scoliosis, cervical spine instability, pectus anomalies, joint hypermobility, and gastrointestinal distress.

Physical exercise activities are important for children with Loeys-Dietz Syndrome. Most parents of children born with Congenital Heart Defects (CHDs) and co-morbidities (e.g., Loeys-Dietz Syndrome, Down Syndrome) are against sports and exercise because of over-protectiveness. Abundance of clinical scientific evidence-based researches demonstrated the importance of physical exercise for improved overall health improvement, heart-lung functions, and fitness. It is vital for children with Loeys-Dietz Syndrome to engage in medically supervised medical fitness program with individualized exercise prescription. Another benefit of organized medically supervised medical fitness program is its favorable benefit to minimize physical inactivity that increases the risks of acquiring coronary heart disease and diabetes.

Medical Exercise Physiology and Down Syndrome:

Medically supervised clinical exercise physiological intervention is important for children with Down Syndrome. Medically supervised clinical exercise physiological intervention is safe and effective in the health improvement and rehabilitation of physically limitations associated with Down Syndrome, particularly congenital heart defects (CHDs) and musculoskeletal anomalies. Most often, children with Down Syndrome have lower overall fitness. Congenital heart defects (CHDs) and musculoskeletal anomalies are not the only barriers to physical exercise in children with Down Syndrome. Other medical conditions, such as gastrointestinal condition, overweight / obesity, diabetes, and osteoporosis are also common barriers to physical exercise in children with Down Syndrome. A safe & comprehensive medically supervised clinical exercise physiological intervention, which includes individualized scientific evidence-based medical exercise prescription emphasizing on cardiovascular and respiratory medical fitness, as well as bone health and muscle strengthening, and postural stability. The effect of postural stability intervention significantly improves functional capabilities and prevents risk of injuries and falls in children with Down Syndrome.

Pediatric Sports Cardiology:
Congenital Heart Defects - Coarctation of the Aorta

There is over 40 types of Congenital Heart Defects (CHDs). Most children born with a CHD called Coarctation of the Aorta (CoA), have coarctation repair or balloon angioplasty performed during childhood. Chest X-ray, ECG, Exercise Cardiac Stress Test, & Echocardiography are important to evaluate the function of left ventricular and the anatomy of the aorta for medical clearance for sports participation.
Three (3) months after surgical of balloon angioplasty, the Heart Kids with normal peak systolic blood pressure during rest and exercise can participate in sports. However, during the 1st post-operative year, it is recommended that the Heart Kids with CoA to avoid high intensity static and contact sports (classes IIIA, IIIB, & IIIC), such as Gymnastics, Body Building, Wrestling, Boxing, Cycling, Decathlon, Triathlon, Speed Skating. It is highly recommended for Heart Kids with CoA repair to participate in clinically supervised medical fitness program to monitor exercise hypertension experiences and long-term cardiovascular risks.

Clinical Sports Cardiology and Special Olympics for children with Congenital Heart Defects and Down Syndrome

Up to 50% of children born with Down Syndrome are also born with Congenital Heart Defects (CHDs). Children and adolescents, even adults with Down Syndrome have a wide range of physical health conditions and delayed motor development. Special Olympics integrated with Sports Cardiology health program is vital for individuals with Congenital Heart Defects (CHDs) in Down Syndrome. Integrated inclusive medical fitness program must be developed and facilitated with individualized scientific evidence-based exercise prescription, emphasizing on motor skill development, in addition to, considerations of the presence of CHDs and orthopedic conditions. Special Olympics integrated with Sports Cardiology programs provide opportunities for individuals with CHDs in Down Syndrome to regularly participate in physical exercise and become physically fit. Regular participation of medical fitness programs, such as Sports Cardiology and Special Olympics, is associated with reduced all-cause morbidity and mortality and hospitalizations.

Pediatric Sports Cardiology:

There is over 40 types of Congenital Heart Defects (CHD). Most children born with a CHD called Coarctation of the Aorta (CoA), have coarctation repair or balloon angioplasty performed during childhood. Chest X-ray, ECG, Exercise Stress Test, & Echocardiography are important to evaluate the function of left ventricular and the anatomy of the aorta for medical clearance for sports participation.
Three (3) months after surgical or balloon angioplasty, the Heart Kids with normal peak systolic blood pressure during rest and exercise can participate in sports. However, during the 1st post-operative year, it is recommended that the Heart Kids with CoA to avoid high intensity static and contact sports (classes IIIA, IIIB, & IIIC), such as Gymnastics, Body Building, Wrestling, Boxing, Cycling, Decathlon, Triathlon, Speed-skating. It is highly recommended for Heart Kids with Coarctation of the Aorta repair to participate in medical fitness program to monitor exercise hypertension experiences and long-term cardiovascular risks.

International Congenital Heart Defect Awareness Month 2022:

Congenital Heart Defect (CHD) is abnormal structure of the heart present at birth. There is over 40 types of known CHDs. Some CHDs may not require much treatment other than periodic visits to the Pediatric Cardiologist. Others can be treated with medications or surgical procedures. CHDs, even though repaired are not cured.

Clinical Pediatric Sports Cardiology:

Atrial Septal Defect (ASD) is one type of Congenital Heart Defect (CHD), characterized by a hole in the upper chambers of the heart. Echocardiography & ECG are required for evaluation. Young heart kids with small or large ASD with normal right heart volume can participate in all sports. Those with mild Pulmonary Hypertension can still participate in Class 1A low intensity competitive sports.

Clinical Pediatric Sports Cardiology:

There is over 40 types of Congenital Heart Defects (CHD). Transposition of the Great Arteries (TGA) is one of the CHDs. Heart kids born with TGA and have undergone Mustard or Senning surgeries can have significant hemodynamic abnormalities. Sports Pre-participation Cardiac Evaluation includes physical examination, chest radiography, echocardiography, electrocardiography, and exercise stress testing. If there is mild or no cardiac chamber enlargement and syncope (fainting), as well as no history of Cardiac Arrhythmias, particularly Atrial Flutters, Supraventricular Tachycardia, & Ventricular Tachycardia, TGA heart kids can participate in low to moderate static and low dynamic competitive sports (Class IA & IIA), such as cricket, golf, diving, and equestrian

Clinical Sports Cardiology:
Special Olympics Artistic Gymnastics for Pediatric Patient with Down Syndrome

For pediatric patient population with Down Syndrome, Special Olympics Artistic Gymnastics provides opportunity and hope to have positive physical health and psycho-social wellness. Children with Down Syndrome have co-morbidities (simultaneous presence of chronic diseases). Up to 50% of those born with Down Syndrome are also born with Congenital Heart Defects. These special heart kids also have other medical conditions, including orthopedic (muscles, bones, ligaments, joints) gastrointestinal, thyroid, visual, as well as ear, nose, & throat disorders. Scientific evidence-based clinical researches have demonstrated that Special Olympics Artistic Gymnastics is specifically effective for motor development and overall health of these special kids. The inclusive health programming must be scientifically evidence-based, as well as must taken into considerations of the individual's health and fitness status and evidence-based individualized exercise prescriptions. Then the children with Down Syndrome will receive the health impact of Special Olympics Artistic Gymnastics inclusive health program, which the health benefits carry through to adulthood.

Clinical Sports Cardiology:
Special Olympics, Sports Cardiology, & Exercise-based Inclusive Health Programs for Children with Special Needs & Disabilities

Special Olympics, sports exercise cardiology, medical health fitness, and exercise-based therapeutic recreational programs are safe and effective inclusive health programs for clinical pediatric patients with disabilities. Adapted sports and exercise oriented inclusive health programs are paving into sports medicine healthcare settings. These sports / exercise inclusive health programs combined with individualized exercise prescriptions play vital role in impacting the overall health of pediatric patients with Congenital Heart Defects, Down Syndrome, Cerebral Palsy, and pediatric neuromuscular disorders. These inclusive health programs in clinical sports medicine healthcare setting is viable in facilitating reinforcement in physical fitness for activities of daily living (ADLs), as well as improvement in heart and lung health of special children. Children with special needs and disabilities who participated in Special Olympics, medical fitness, and exercise-based inclusive health programs are healthier than peers who have not participated.

Clinical Pediatric Cardiac Physiology:
Clinical Pediatric Sports Cardiology

The ductus arteriosus is normal fetal connection between the aorta and the pulmonary artery. The ductus arteriosus closes shortly after birth. Patent Ductus Arteriosus (PDA) occurs when the opening between the two major blood vessels failed to close.
Heart kids with small PDA and normal left heart chamber can participate in all sports and exercise. However, heart kids with large PDA that causes enlargement of the left ventricle, should undergo either transcatheter closure or surgical closure of the PDA before any sports participation. Three months post-interventional closure of PDA, heart kids with no symptoms, as well as, absence of pulmonary hypertension or left ventricular enlargement can participate in sports.
Congenital heart defects (CHDs), even though repaired are not cured. Heart kids require lifelong care. Healthy lifestyle - regular exercise, healthful eating, and no smoking - are vital for future health. Reduced physical exercise significantly influences the future health. In this age of digitalization, which leads to increased sedentary (physically inactive) lifestyle negatively impact the health of heart kids, who are susceptible to acquired coronary heart disease, diabetes, and obesity, when successfully transitioned into adulthood. Clinical scientific evidence-based researches demonstrated that the social return on investments of health is greater in clinical patient population participants of medical fitness programs with individualized exercise prescription than general participation of sports and physical activity.

Clinical Pediatric Sports Cardiology:

There is over 40 types of Congenital Heart Defects (CHD). Tetralogy of Fallot (ToF) is one of the CHD. ToF is characterized by a large Ventricular Septal Defect (VSD), Over-riding Aorta, Pulmonary Stenosis, & Right Ventricular Hypertrophy. Diagnostic evaluation includes chest radiography, echocardiography, cardiac MRI, ambulatory ECG, & Exercise Stress Testing.
Heart Kids with successful surgical repair can participate in all sports. Heart Kids with significant pulmonary regurgitation and right ventricular volume overload, residual right ventricular hypertension, or atrial / ventricular tachycardia can still participate in low-intensity Class 1A competitive sports, such as cricket, bowling, & golf.

Medical Exercise Physiology and Down Syndrome

Medically supervised clinical exercise physiology intervention is important for children with Down Syndrome. Medically supervised clinical exercise physiology intervention is safe and effective in the health improvement and rehabilitation of physical limitations associated with Down Syndrome, such as congenital heart defects (CHD) and musculoskeletal anomalies. Most often, children with Down Syndrome have lower overall fitness. Barriers to physical exercise in children with Down Syndrome includes medical health conditions, such as congenital heart defects, musculoskeletal anomalies, gastrointestinal conditions, overweight / obesity, diabetes, and osteoporosis. A safe and comprehensive medically supervised medical exercise physiology intervention, emphasizing on cardiovascular and respiratory fitness, bone and muscle strengthening, and postural stability, should be clinically prescribed. The effect of postural stability intervention significantly improves functional capabilities and prevents risk of injuries and falls in children with Down Syndrome.

ClinicalPediatricExercisePhysiology
ClinicalPediatricSportsCardiology

Clinical Pediatric Sports Cardiology:
Congenital Heart Defects (CHD)

Congenital Heart Defect (CHD) is abnormal structure of the heart present at birth. Most parents of heart kids are against sports and exercise due to over-protectiveness. Children born with CHDs often do not engage in regular exercise. Abundance of clinical scientific evidence-based researches demonstrated the importance of physical exercise for improved overall health improvement, heart-lung functions, and fitness. It is vital for children with CHDs to engage in medically supervised medical fitness program with individualized exercise prescription. Another benefit of organized medical fitness programs is its favorable benefit to minimize the risks of acquired atherosclerotic coronary heart disease and diabetes.
Vigorous exercise may increase risk of myocardial infarction (heart attack) in adults with atherosclerotic coronary heart disease. But congenital heart disease in children and adolescents is different. Regular exercise and sports participation are major contributors to normal growth and development of children from physical, emotional, and psycho-social standpoints. According to Besthesda Guidelines for Athletes with Cardiovascular Abnormalities, utilized by Sports Cardiologists and Cardiac Physiologists, children with CHDs do not need restriction from sports participation. In fact, it is recommended that heart kids should engage in medically supervised medical fitness program with individualized exercise prescription.

Clinical Pediatric Sports Cardiology:
Kawasaki Syndrome

Kawasaki Syndrome is also known as Acute Systemic Vasculitis. Kawasaki Disease is the most common cause of acquired heart disease in children. Kawasaki Disease often occur in children below 5 years old but sometimes affects older children and teenagers too. Kawasaki Disease causes cardiac complications, particularly Coronary Aneursyms. Because of the coronary artery morphology, all patients with Kawasaki Disease must avoid sedentary lifestyle. After health recovery, in between 6 - 8 weeks, children are encouraged to participate in all sports. Exercise stress tests are performed by Sports Cardiologists for the eligibility and recommendation of sports, based on the test intepretations.

Clinical Pediatric Cardiac Physiology:
Clinical Pediatric Sports Cardiology

Genetic mutation of SCN5A can cause Congenital Sick Sinus Syndrome (CSSS) in children. Heart kids born with Congenital Heart Defects (CHDs) & undergone heart surgeries may also acquire Sick Sinus Syndrome (SSS). The Sinoatrial Node is the natural heart pacemaker that initiates heartbeats. In SSS, the sinoatrial node is not able to adjust the heart rate of the level of physical exercise activities. The heart rate is irregular and slow. Sometimes, there is long pauses in between heartbeats. The slow & irregular heartbeats with long pauses may cause dizziness, fainting & decreased physical endurance during exercise activities. There is increased risk of development of Atrial Flutters & Atrial Fibrillation.

Clinical Pediatric Cardiac Physiology:
Clinical Pediatric Sports Cardiology

Children born with a type of Congenital Heart Defect called Atrial Septal Defect (ASD) can still participate in sports and exercise activities. ASD is characterized by a hole in the upper chambers of the heart. Heart Kids with ASD often undergo ASD closure by either surgical or interventional catheterization operations. Six (6) months after operations, the Heart Kids can participate in all sports. Any presence of abnormalities, such as Pulmonary Hypertension, Cardiac Arrhythmia - Atrial / Ventricular Tachycardia or 2nd / 3rd Degree AV Block - and Myocardial Dysfunction, requires Stress Echocardiography for evaluation for individualized exercise prescriptions / medically supervised exercise program.

Clinical Cardiac Exercise Physiology:
Down Syndrome and Associated Congenital Cardiac and Orthopedic Issues

Children with Down Syndrome have associated musculoskeketal issues, largely related to generalized ligamentous laxity and joint hypermobility. The orthopedic conditions includes atlanto-axial instability, scoliosis, hip instability, slipped capital femoral epihysis, patellofemoral instability, and foot disorders, such as pes planus and hallux valgus. Up to 50% of patients with Down Syndrome are also born with Congenital Heart Defects (present at birth), most commonly Atrioventricular Septal Defect, Atrial Septal Defect, Ventricular Septal Defect, Patent Ductus Arteriosus, and Tetralogy of Fallot. Down Syndrome is also associated with other various congenital anomalies, such as Duodenal Atresia, Hirschsprung, and Intestinal Atresia.
It is important for children with Down Syndrome to engage in Clinical Exercise Physiological Intervention. Intervention should be long term and start as early as possible. If musculoskeletal conditions associated with Down Syndrome are not treated with appropriate exercise prescriptive intervention, it can lead to disability. Potential disabilities includes "clumsiness" in walking and jogging, poor dexterity in hands, such as difficult in writing, coloring, feeding with spoon and fork, and self-care dressing. Moreover, clinical exercise physiological intervention should be comprehensive and integrated with cardiac rehabilitation. Abundance of scientific evidence-based researches, utilizing clinical cardiac exercise stress testing demonstrated that cardiac rehabilitation produces significant benefits including improved cardiorespiratory function, overall health and fitness in children and adults with Down Syndrome.

Clinical Sports Cardiology:

Physical inactivity, obesity, and chronic diseases, particularly heart disease, are on the rise worldwide. The prevalence of heart disease greatly impacts population health and economic costs of health disparities and pre-matured death. Moreover, during the global pandemic of Covid-19, sports and exercise programs are more than ever vital for the prevention and rehabilitation of Covid-19 infection and Long Covid, respectively. It requires medical healthcare - sports cardiology, which is a combination of cardiology and sports medicine - as well as sports and exercise programs, healthful health behaviors, and physical spatial acessibility to work synergistically for effective population health improvement.

Clinical Sports Cardiology:
Down Syndrome

Clinical pediatric patient population with Down Syndrome presents with hypotonia, muscle weakness, ligamentous laxity, decreased functional capacity, and poor postural control. Moreover, 50% of children born with Down Syndrome are also born with Congenital Heart Defect (abnormal structure of the heart present at birth). Due to these conditions, children with Down Syndrome require specific clinical exercise physiological interventions. Children with Down Syndrome are more vulnerable during and / or after the pandemic of Covid-19. The risk factors associated with increased risk of hospitalization and morbidity due to corona virus include overweight / obesity, heart disease, diabetes, hypertension and co-morbidities. The global pandemic of Covid-19 has brought forward the importance of active healthy living. Medically supervised Home Health Medical Fitness is vital for children with Down Syndrome.

Clinical Cardiac Physiology:
Clinical Sports Cardiology in Down Syndrome

It is common for clinical patient population with Down Syndrome to have alterations in autonomic nervous system (ANS). Individuals with Down Syndrome also experience low heart rate during exercise. The chronotropic incompetence (inability for the heart rate to increase adequately during exercise) may occur during maximal exertion. Dysautonomia, chronotropic incompetence, and altered neurosecretion can increase exercise intolerance, causing physical fatigue and post-exercise syncope (fainting). Clinical scientific evidence-based research demonstrated that 6 months of medically supervised clinical exercise physiological interventional treatment can improve sympatho-vagal balance, resulting in better heart rate recovery. Regular home health clinical exercise physiological intervention with sports medical follow-up is promising for healthy growth and development in patients with Down Syndrome.

Clinical Cardiac Physiology:
Sports Cardiology and Down Syndrome

Physical fitness is defined as characteristeristics that contribute to cardiovascular health, ideal body composition, flexibility, muscular strength, and endurance to perform moderate physical exercise and activity of the daily living, such as walking up the staircase and carrying groceries. Clinical patient population with Down Syndrome has higher risk of developing heart disease, diabetes, obesity, and osteoporosis because of poor physical fitness. Physical inactivity and physical limitations associated with Down Syndrome, such as Congenital Heart Defects, low heart rates, pulmonary abnormalities, and multiple musculoskeletal issues, namely ligamentous laxity, atlanto-axial instability, patellofemoral instability, hip instability, slipped capital femoral epiphysis, and foot disorders significantly contribute to poor physical fitness and physical limitations. Home Health Medical Fitness exercise prescription based on International Gold Standard ACSM Clinical Guidelines is safe and effective to improve heart and lungs fitness, as well as orthopedic conditions in clinical patient population with Down Syndrome.

Clinical Sports Cardiology:

The SARS-CoV-2 infection (Covid-19 disease) often leads to significant disabilities and deconditioning because of ICU-acquired weaknesses, myopathies, and neuropathies. Scientific clinical studies demonstrated that post-Covid patients display greater loss of autonomy than post-cardiac surgical patients. Individualized rehabilitation treatment is proven effective for the functional recovery.

Clinical Sports Cardiology:
Return on Investments of Health and Sports Exercise

Physical exercise program were an integral part of life few generations ago. Today, children's active play has also declined. Physical exercise in children is essential for healthy growth and development. Reduced sports participations, physical exercise, and active play significantly influence future health. Sedentary lifestyle leads to the development of chronic diseases, including but not limited to heart disease, diabetes, stroke, clinical depression, dementia, and certain cancers, when the children successfully transitioned into adulthood.
Clinical scientific evidence-based researches demonstrated that today's children have shorter life expectancy than their parents. It is estimated that Millennials may die five (5) years younger than the previous generations. Impact investing in health and sports exercise is defined by strategic investments for optimal physical health, mental health, physical fitness, and increased quality of life. Clinical scientific studies highlighted that the social return on investments of health is greater in clinical patient population participants of medical fitness programs with individualized exercise prescription than general participation of sports and physical activity. Nevertheless, sports and physical activity are still important to overall health.

Clinical Sports Cardiology:
Cerebral Palsy

Cerebral Palsy (CP) is a neurodevelopmental disorder because of injury to the brain. Cerebral Palsy (CP) is the most common childhood disability, with the prevalence of 1.5 - 3.8 per 1000 births worldwide. The clinical hallmark of CP is disordered motor control. Both children and adults with CP have reduced cardiorespiratory and functional capacity. Lack of movement control causes energy expenditures to be high even when exercising in low output levels; therefore, requiring individualized exercise prescription. Reduced cardiorespiratory endurance and functional capacity in CP increases the risk of developing obesity, leading to cardiovascular (heart) disease and diabetes, as well as other chronic diseases, such as osteoarthritis. It is important to encourage medically supervised medical fitness intervention, according to clinical guidelines to minimize the risk of chronic diseases and complications of early physical functional loss.

World Down Syndrome Day:
Congenital Heart Defect in Down Syndrome

The prevalence of Congenital Heart Defects (CHD) in Down Syndrome in Malaysia is similar to other high income countries. Up to 55% of babies born with Down Syndrome are also born with CHD. The most common CHD in Down Syndrome includes Atrioventricular Septal Defect (AVSD), Ventricular Septal Defect (VSD), Atrial Septal Defect (ASD), Patent Ductus Arteriosus (PDA), and Tetralogy of Fallot (ToF). The American Academy of Pediatrics (AAP) recommended Cardiac Screening & Diagnostics to be preferably be performed within 6 weeks of age to avoid complex complications, particularly Pulmonary Hypertension, that makes corrective heart surgeries impossible.

Clinical Sports Cardiology:
Clinical Exercise Physiology and Down Syndrome

Clinical patient population with Down Syndrome often experience barriers to physical exercise participations. There is presence of clinical scientific evidence that as individuals with Down Syndrome advance in age, they become more physically inactive. Consequently, reducing overall health and fitness, as well as quality of life. Medically supervised clinical exercise program with individualized exercise prescription plays an important role in clinical patient population with Down Syndrome. Up to 50% of those born with Down Syndrome are also born with Congenital Heart Defects (CHDs). Medically supervised clinical exercise program with individualized exercise prescription improves heart and lung functions and prevents chronic diseases (heart disease, diabetes, obesity). Moreover, patient-centered clinical exercise programming with individualized exercise prescription also improves fitness for activities of the daily living (ADLs), such as walking to the supermarket, carrying groceries, walking up and down the staircase, etc., resulting in improved independence living, improved self-esteem, confidence, and quality of life.