Bastioned by the AAP’s statement¹ in support of school reopenings amidst the ongoing COVID-19 pandemic, school governing bodies everywhere have established a spectrum of different masking requirements for students. Some may argue that masking could be disruptive to learning and development, particularly in young children. However, the caveat in the AAP’s statement must not be forgotten: that the school reopenings are to be driven by science and safety. Arrangements for social distancing at school are frequently changing, with some schools having greater capacity than others to space out students, and some school districts electing to continue the school year entirely online. Parents and guardians are often constrained by work or other life circumstances, including lack of financial or technological resources, giving them little choice but to send their children back to in-person education. Consistent masking practices for as many children as possible at school will greatly help to mitigate the associated risk of students and staff contracting and spreading COVID-19. Pediatricians are uniquely poised to advocate for this low-cost, minimally invasive intervention that may save countless lives of all ages. 

Without clear scientific guidance indicating that children do not contribute significantly to the spread of the pandemic, we are left to answer the question of how to proceed this academic year.

We currently do not have sufficient scientific evidence to definitively say whether schoolchildren are significant drivers of transmission. Most children in America lost their primary source of in-person social activities (and thus, their primary opportunity to transmit infectious disease) when schools promptly closed last spring in response to the pandemic. Compared to most adults, the average school-aged child would have had little compelling reason to leave home during the pandemic. The consequences of incorrectly presuming that children have little role in COVID-19 transmission should not be underestimated. Modeling data from Johns Hopkins University’s School of Public Health, researchers at Cincinnati Children’s Hospital have estimated that state school closures in March 2020 may have reduced the USA’s overall incidence of COVID-19 by 39% that spring, even after researchers adjusted for effects from other state policies (such as stay-at-home/shelter-in-place orders) enacted to counter the pandemic.² Notably, this study compared two extremes: the total school closure that we implemented versus the hypothetical continuation of normal schooling with no masking, increased sanitation, or social distancing.  

Without clear scientific guidance indicating that children do not contribute significantly to the spread of the pandemic, we are left to answer the question of how to proceed this academic year. In medicine, we are taught to analyze risks versus benefits. The consequences and cost of an expanding pandemic – which the world has already encountered – are large compared to the risks of facial masking. With a few exceptions (children younger than 2 years old and those who are unable to remove the mask without assistance), the CDC recommends masking for nearly everyone.³ Masking may prove especially difficult and unfeasible for certain individuals, such as children with developmental delay or significant chronic respiratory disease. These inevitable exceptions heighten the importance of consistent masking practices for everyone else who can tolerate and wear a mask.  

Many parents understandably are concerned that students will have difficulty discerning the emotions and expressions of masked educators and staff. A study conducted with 80 children (3-10 years old) found that younger school-aged children do not demonstrate statistically significant impairment in correctly categorizing still images of facial expressions underneath mouth coverings compared to completely unobstructed facial expressions.  Only children ages 7-10 years old demonstrated statistically significant difficulty in performing this task, and the researchers theorize that this could indicate that older children rely more heavily on the appearance of the mouth to interpret facial expressions compared to younger children who may focus more selectively on the eyes as opposed to holistically interpreting the entire facial expression. Even in the older children, the difference in accurate identification of masked and unmasked expressions was only about 25% at most. Additionally, the students in the study did not have the benefit of hearing the tone of voice and social context behind a given masked facial expression as they would in school.⁴  Students and school employees should be aware that clear face shields are not acceptable substitutes for face masks, per CDC recommendations. Teachers of certain classes (such as special education for hearing-impaired students or English-as-a-second-language) may find it especially useful to obtain a clear face mask, but given their cost and lower degree of comfort, the CDC has made no recommendation for all students and educators to preferentially use them. 

As schools reopen for in-person activities this fall, and as the annual check-ups (and sick visits!) inevitably trickle into our clinics, physicians have a unique opportunity to advocate for not just the children, but also for the teachers and families who are instrumental to their well-being. Masking is a simple intervention that can reduce the transmission of not just COVID-19 but also of influenza and the other more familiar respiratory illnesses that are already beginning their annual circulation through many of our communities. We would be wise to safeguard whatever progress we have already made in combating the pandemic by continuing to wear facial masks, along with appropriate disinfecting and social distancing. Besides, masking can actually be fun – just ask your friendly neighborhood superhero. 

References 

1. https://services.aap.org/en/news-room/news-releases/aap/2020/pediatricians-educators-and-superintendents-urge-a-safe-return-to-school-this-fall/ 
2. Auger KA, Shah SS, Richardson T, et al. Association Between Statewide School Closure and COVID-19 Incidence and Mortality in the US. JAMA. 2020;324(9):859–870. doi:10.1001/jama.2020.14348 
3. https://www.cdc.gov/coronavirus/2019-ncov/community/schools-childcare/cloth-face-cover.html 
4. Roberson D, Kikutani M, Döge P, Whitaker L, Majid A. Shades of emotion: what the addition of sunglasses or masks to faces reveals about the development of facial expression processing. Cognition. 2012;125(2):195-206. doi:10.1016/j.cognition.2012.06.018 

Ealing Tuan Mondragon, MD