CDC Recommends Younger Kids Wear Masks; Kentucky Says It Depends

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After three months of closures, child care centers have reopened in Kentucky with a full slate of new safety guidelines.

There are temperature checks. Groups are capped at 10 kids. Playground time is staggered. The “lost and found” bin has been eliminated. Toys are sanitized between use. Field trips are canceled.

Adult staffers must be masked, unless they’re six feet away from another person. That’s consistent with the “universal masking” plank of the state’s plan to reopen the economy.

But for children, masking rules are looser.

The American Academy of Pediatrics and Centers for Disease Control recommend children 2 and older wear masks in public when social distancing is difficult. In daycare, “when feasible staff members and older children should wear face coverings within the facility,” according to CDC guidelines.

But Kentucky is recommending against masks for children 5 and younger. For children older than 5, masks in child care centers are recommended — but still not required.

State guidelines say the masking age is older than federal guidelines because children 5 and under face “increased risks of suffocation and strangulation.”

But experts and child specialists suggested the state guidelines have as much to do with the practical realities of caring for children as settled science about viral transmission.

Children And COVID

Although children are rarely debilitated by COVID-19 — only a single person under the age of 30 has died from COVID-19 in Kentucky — research is mixed on the extent to which kids transmit the virus.

“The risk of transmission among a group of children, based off of the data, does appear to be lower than the risk among even young adults, adults and older individuals,” said Annabelle de St. Maurice, assistant professor of pediatrics and infectious disease expert at UCLA.

There are also reports of a possible link between COVID and pediatric multisystem inflammatory syndrome (PMIS, or MIS-C), a very rare but serious disease that might explain several deaths among children who tested positive for the new coronavirus. Research is ongoing, and experts emphasize it’s premature to draw sweeping conclusions.

De St. Maurice said it’s important to do “whatever we can do” to prevent transmission in group settings. That includes familiar advice, such as keeping sick kids home, practicing hand hygiene and social distancing, and wearing masks. De St. Maurice encourages schools to promote masks “as much as possible.”

Under new safety guidelines for school re-opening in Kentucky, students first grade and above will be required to wear masks in school if six-foot distancing isn’t possible. Masks will also be required on the bus.

Masks are widely believed to be an important part of viral containment. In Hong Kong, one of the most densely populated metro areas in the world, just five people have died of COVID-19 out of 7.5 million residents, according to Hong Kong’s government. Experts cite social distancing and universal mask-wearing.

But when or if children should don masks is more complicated.

The benefits of child mask-wearing are straightforward. But so are the risks: young children are less able to remove their mask in an emergency, and they’re also more likely to touch and contaminate their masks.

“In the youngest children, trying to put a mask on them all day, that mask is probably going to get wet and gross, and they’re going to play with it and take it off, and someone’s going to need to put it back on them,” said Kristina Bryant, professor of pediatrics at the University of Louisville and the hospital epidemiologist at Norton Children’s Hospital.

“I think that’s part of the rationale driving the recommendations for daycare: How practical is it to keep a mask on a 2- or 3-year-old all day long?”

Practicality was a major concern for state officials. “In Kentucky, we chose to recommend that children ages 5 and older wear masks because they are likely more able to comply,” said Susan Dunlap, spokesperson for the Kentucky Cabinet for Health and Family Services.

Still, there are reasons to encourage able, younger children to wear masks. If children infected with COVID-19 are presymptomatic or asymptomatic, they might unknowingly spread the virus through child care facilities or schools, jeopardizing the staff and their own families.

Some states have already seen issues after child care facilities re-opened. In Texas, where there never was a mask requirement for child care centers, Gov. Greg Abbott ordered new rules after a spike of new COVID cases linked to child care.

Norton Children’s Hospital recommends children 2 and older wear masks in public when social distancing isn’t possible. So does the Kentucky Children’s Hospital, in Lexington.

“The CDC recommended from two years and up, everyone should be wearing a mask as much as possible in a public setting, especially at the hospital,” said Jenna Cook, a child life specialist at the Kentucky Children’s Hospital.

State rules and recommendations are important because mask-wearing needs to be universal — above 80% of the population, as one study suggested — in order to be effective.

“The 4-year-old wearing a mask protects other people; the mask doesn’t protect the 4-year-old,” said Bryant. “It only works if everybody for whom it’s safe wears it.”

Judgment Call For Younger Children

The disagreement centers on what ages can safely wear masks. Experts agree children under 2 should not wear masks. “Babies can’t take the mask off themselves. If they’re overheating or can’t breathe, they don’t have a moment to take it off themselves,” said Ashley Rapske, a child life specialist at Kentucky Children’s Hospital. She’s a health care professional who provides emotional support and coordinates activities with children and their families.

The development of older kids ranges more widely than younger ones. A 5-year-old, for instance, might face similar risks with masks depending on their needs.

Eric Friedlander, secretary of the Kentucky Cabinet for Health and Family Services, has advised children to wear masks as they are able. Still, he acknowledged, “it’s a judgment call on a child’s developmental ability.”

Child care operators can recommend mask usage for children ages 2-5 “as long as the child is developmentally able to comply and it is not felt to be a safety risk to the child,” Dunlap added.

Steven Stack, commissioner of the state’s public health department, believes such a recommendation would not go against the guidelines but would set an even higher bar, according to Dunlap.

“We know children get infected with COVID-19. And, it seems very likely that they are able to transmit the disease to others,” Dunlap said. “Unfortunately, we don’t know how effective they are as transmitters when compared with older persons.”

Another challenge is that Americans have no history of wearing face coverings in public and are developing mask norms in real-time. When adults balk at wearing a mask, children often pick up a signal, experts advise.

Cook and Rapske outlined simple steps for parents to familiarize their children with masks, including modeling mask-wearing, teaching children how to put on and take off a mask, wearing masks around the home as practice, and using the masks as part of creative play such as on stuffed animals or action figures.

To combat the stigma, signs around Norton Children’s Hospital are appealing to kids directly: “Superkids, like superheroes, wear masks.”

“Kids aren’t used to wearing masks,” Bryant said. “But kids know superheroes, and superheroes wear masks.”