Pediatricians Say Children Should Return to School. Are They Out of Their Minds?
I have to admit that as a front-line pediatrician caring for hospitalized COVID-infected children, I was caught off guard by the American Academy of Pediatrics’s release last week of a guidance document stating, “the AAP strongly advocates that all policy considerations for the coming school year should start with a goal of having students physically present in school.” (Full disclosure: while I hold a leadership position in the AAP, I was not involved in crafting this policy, and I am not speaking for the AAP here, only for myself.)
The recommendation flew in the face of my instincts regarding COVID, especially at this moment when cases seem to be exploding in my state of North Carolina. And yet I know many of the people involved in crafting this advice, and I’m confident that none of them are delusional, impaired, or irresponsible, so I figured I’d better research why they think we should cram our kids into big viral incubators less than two months from now.
To grasp this advice, it helps to know the AAP’s priorities. The AAP defines its mission as, “to attain optimal physical, mental, and social health and well-being for all infants, children, adolescents, and young adults.” We don’t just strive to keep kids healthy. We work to advance mental and social health as well, for all young people. Coronavirus is a nasty, scary, potentially deadly disease, but if we’re going to help every child thrive, we’re going to have to balance it against other concerns.
Kids, of course, are not the only people in schools. Without teachers, administrators, coaches, environmental services staff, and cafeteria workers, schools are just buildings. Their health is important, as is the health of parents and extended family members who live with and care for children. So, how exactly is that supposed to work?
Kids, of course, are not the only people in schools. Without teachers, administrators, coaches, environmental services staff, and cafeteria workers, schools are just buildings.
The best data that we have to tell us that kids pass COVID to adults and perhaps to each other much less often than adults pass it to kids (references below for the curious). No one can guarantee that children won’t infect school personnel or family members, but the risks seem to be much lower, around 0–10% of the adult transmission rate. (1–6) Why this should be, I don’t know — social distancing, mask-wearing, and hand-washing seem less common among children while shouting and close contact seems more common — but those are the data, and they hold up across multiple studies and countries.
Children also seem less likely to become infected after exposure to COVID, at around half the rate of adults. (7) When infected, they are less likely to become symptomatic and less likely to become critically ill or die. That’s not to say that critical illness and even death don’t occur among children, just that it’s much less common than in adults.
Personally, I’m keeping my eye on Multisystem Inflammatory Syndrome in Children (MIS-C), a potentially lethal condition that can affect many organ systems including the heart. (8) It’s not clear how many children who contract COVID eventually go on to suffer MIS-C; this complication may lag the initial infection by weeks. So far MIS-C has remained quite rare, but between now and August we may detect more cases, which would change our risk equation.
If there were a good alternative, we wouldn’t be talking about sending kids back to school, but our experience from the spring tells us that staying home is not going to be a workable option for many children or their families, and not just because homeschooling is really, really hard. Let’s look at what kids miss when they don’t go to school:
- Learning (obviously). It turns out that teaching is a science, an art, and a discipline, and that years of study and experience help, a lot.
- Socialization. School is where most children learn how to interact with other people. That takes lots of practice and, well, other people.
- Food. Food insecurity affected up to 1 in 5 children before the pandemic,(9) and since then many parents have lost their jobs. School lunch and breakfast may be the only reliable nutrition for a surprising number of kids.
- Safety. School personnel are attuned to their students’ wellbeing, and they notice when a child’s demeanor or performance changes or when a child shows up poorly groomed or sporting unusual bruises. When responsible, trained adults don’t see children, abuse and neglect go unreported.
- Mental and physical health services. Many children receive counseling and chronic disease management from school-based therapists, nurses, and clinicians. When parents lack transportation or health insurance, the schools often serve as a backstop, averting disaster.
In other words, there are no perfect answers. We send kids back to school and risk spreading COVID, or we keep them home and many suffer there as well, in addition to preventing their parents from working. So we’re shooting for school. But not school like it was. This is COVID-era school. That means, among other things:
- Smaller class sizes and cohorts. Can students attend school in groups by half-day, day, or week?
- Less mixing. Minimize hallway time. Move teachers, not students, when possible. Consider how lunch, physical education, band, and other activities can be re-imagined to reduce the risk of viral spread. Keep kids 6 feet apart ideally, but 3 feet may be almost as good.
- Get outside as much as possible. Obviously thunderstorms, heat, cold, insects, and a lack of projection equipment may limit this option, but in general, it’s safer outside than inside.
- Not everyone goes back. Schools will need to provide options for vulnerable children and families that minimize their risks. Home-based instruction and remote learning must expand to accommodate these families. Outbreaks may also require that affected students pivot to online classes periodically.
- Masks, masks, and more masks. Also, handwashing and disinfecting high touch surfaces. I know, young children will mess with the masks; if they do, it may not be worth it. Teens will resent them. Teachers won’t love them. But masks work, period, so where practical, we’re going to need them. And before you tell me people will suffocate, I wear an N95 for hours a day in the hospital, and I recently pushed a stalled car 1/3 of a mile in coastal North Carolina July humidity while wearing one (long story), so yeah, no. In the very, very rare cases in which someone has a lung or heart condition so severe that wearing a mask poses an additional risk, of course there will be exceptions, but those people are at far too high a risk to send to school.
Right now we have two big questions. First, how much do we care about all the things that schools provide? Because with investment in schools — teachers, staff, food service, facilities, busses — they can be made safer. Maybe now that we’ve seen what it’s like to live without school we’ll be willing to make the necessary investments, understanding that yes, it will cost money, but the payoff on such investments is vast, immediately by getting parents back to work and later by educating the workforce of the future.
Second, can everyone please just wear their masks? And wash their hands? And follow distancing guidelines? It’s July. There’s still time to crush this curve, but barely. The single most important factor in getting kids back to school safely is how many of us have COVID infections when school starts. If we can get that number low enough, then we can turn COVID into a dangerous but rare infection, not a society-stalling disaster. If you won’t do it for yourself or for your neighbor, please, do it for the kids. School can be safe, but only if we make it so.