Pediatricians' Recommendations for Schools this Coming Fall

The American Academy of Pediatricians (AAP) wants to make this clear: Pediatricians strongly advocates that all policy considerations for the coming school year should start with a goal of having students physically present in school. The academy warns us of the negative impacts on children due to school closures. The Brookings Institute also reminds us of what we now already know with regard to school closings during World War II. Psacharopoulos and others tell us that these still have an impact on the student's lives some forty years later. They even try to put an estimate on the cost of school closings for four months, reflected in a loss in earnings, in the US: Two and a half trillion dollars. Of course, there is no price tag for saving just one life from COVID-19. Thus, AAP is likewise mindful of the safety concerns. 

First, the AAP evaluates what we know so far regarding the epidemiology of COVID-19. The AAP notes:

SARS-CoV-2 appears to behave differently in children and adolescents than other common respiratory viruses, such as influenza, on which much of the current guidance regarding school closures is based. Although children and adolescents play a major role in amplifying influenza outbreaks, to date, this does not appear to be the case with SARS-CoV-2. Although many questions remain, the preponderance of evidence indicates that children and adolescents are less likely to be symptomatic and less likely to have severe disease resulting from SARS-CoV-2 infection. In addition, children may be less likely to become infected and to spread infection.

Except for a very small number of cases involving children, there is indeed plenty of evidence that K-12 school aged individuals have much lower cases. Take, for example, the age distribution of COVID-19 cases in the state of California.

 

Although about 17 percent of California's population is 5 to 17 years old, only 6 percent of COVID-19 cases belong to this group and there are no recorded deaths for this school-aged individuals as of June 28, 2020. 

For the reason that children seem to be affected less by SARS-CoV-2, the AAP recommends that measures for children can be different from those recommended for adults. A social distancing of 3 feet, not 6 feet, is suggested especially if school children are already wearing a mask. On the other hand, adults should maintain a 6 feet social distance. Staff and faculty meeting should remain online since adult-to-adult transmission is clearly much more prevalent. Parents should not enter school buildings. 

Among the children, there is also differentiation. The following is recommended for pre-K:

• Cohort classes to minimize crossover among children and adults within the school; the exact size of the cohort may vary, often dependent on local or state health department guidance.
• Utilize outdoor spaces when possible.
• Limit unnecessary visitors into the building.

These are for elementary school children:

• Children should wear face coverings when harms (eg, increasing hand-mouth/nose contact) do not outweigh benefits (potential COVID-19 risk reduction).
• Desks should be placed 3 to 6 feet apart when feasible (if this reduces the amount of time children are present in school, harm may outweigh potential benefits).
• Cohort classes to minimize crossover among children and adults within the school.
• Utilize outdoor spaces when possible.

These are for middle and high school students

• Universal face coverings in middle and high schools when not able to maintain a 6-foot distance (students and adults).
• Particular avoidance of close physical proximity in cases of increased exhalation (singing, exercise); these activities are likely safest outdoors and spread out.
• Desks should be placed 3 to 6 feet apart when feasible.
• Cohort classes if possible, limit cross-over of students and teachers to the extent possible.

And the following may assist with cohorting in middle/high school:

• Block schedule (much like colleges, intensive 1-month blocks).
• Eliminate use of lockers or assign them by cohort to reduce need for hallway use across multiple areas of the building. (This strategy would need to be done in conjunction with planning to ensure students are not carrying home an unreasonable number of books on a daily basis and may vary depending on other cohorting and instructional decisions schools are making.)
• Have teachers rotate instead of students when feasible.
• Utilize outdoor spaces when possible.
• Teachers should maintain 6 feet from students when possible and if not disruptive to educational process.
• Restructure elective offerings to allow small groups within one classroom. This may not be possible in a small classroom.

As the AAP notes, school reopening should focus on optimal learning (face-to-face) and mitigating COVID-19. It is not possible to eliminate fully the risk of SARS-CoV-2 infection, but we can certainly minimize the risks. Either social distancing or wearing a face mask is evidently effective in minimizing the transmission of this virus. If we can maintain social distance, a face mask is not necessary, but if we cannot keep distance from others, everyone must wear a face mask. Most of the infections that have occurred across the globe are from individuals exhibiting symptoms. Whether asymptomatic persons can transmit the disease remains controversial, but what is currently known is that most infections have come from symptomatic individuals. We are not completely in the dark though much remains to be known. However, the negative impact of school closure is known, and we must weigh this heavily as we plan for this coming school year.