COVID-19 & Returning to School
Is virtual or in-person school the best option for your child in Fall 2020? The Covid-19 pandemic leaves us all facing the tough decision of how to keep our children and families safe and sane. As a pediatrician and a mother, I’ve been wrestling with the same questions. So, here are my thoughts on the recent American Academy of Pediatrics guidelines, along with a caveat that as we learn more over the next few months, my recommendations and opinions may change. A separate discussion in teenagers can be found here.
The AAP recommendations were designed to help guide school policies across the country for the upcoming year. Their recommendations are thoughtful, and they take into account both the current data on COVID-19 and the crucial role that schools and teachers play in our children’s wellbeing. Many families rely on schools for childcare, meals, and to help keep their children safe. Some parents do not have an option to work from home, or do not have the resources to provide virtual learning opportunities for their children. Teachers are also invaluable in identifying children with learning issues, mood disorders, and those in unsafe home situations, so we can provide resources to help those children thrive. In these situations, the benefits of in-person school likely outweigh the risks. Ensuring that in-person options are available for these families is the right thing to do.
With that said, whether schools should be offering in-person schooling is a separate question from whether any particular family should choose to return to school this fall. For families who are fortunate enough to have the option of choosing between in person and virtual school, what follows is an outline of some of the factors that I’ve been discussing with parents and considering for my own children:
Children are Less Likely to Transmit COVID-19
Recent information suggests that children may not be transmitting as much as we once thought. We know from Tuberculosis data that young children likely are not as effective at aerosolizing as adults, and many fewer children have been positive than would be predicted based on community numbers. Surveillance data indicates that children comprise only 7% of positive cases in the United States, and although infected children shed the virus, transmission by younger children is less common. Schools have opened with safety protocols in place in many other countries, largely successfully. That said, many of these re-openings occurred in countries with flattened curves, and better testing capacity/contact tracing than has been established in the US at this point.
It makes sense that in communities where cases are rising rapidly, children are more likely to have the infection compared to their counterparts in other areas with lower infection rates. And the infection rates are rising in several places. On July 9, 2020, the AAP published a report providing some of the available child Covid-19 data. Since states began reporting, there have been approximately 200,000 cases of Covid-19 in children; 61,000 of those cases were reported between June 25 and July 9, 2020, which is a 45% increase in the number of child cases. Not every state reports age distribution, so the numbers are not entirely accurate, but this provides a good indication that our situation is continuing to evolve.
A recent outbreak in Israel is thought to be related to large community gatherings (such as weddings) and Chinese studies also support the idea that children usually catch COVID-19 from adult family members. As such, maintaining social distancing practices for adults—and avoiding community gatherings—is probably more important to protect our children than keeping them from school.
It is also reassuring that children for the most part handle COVID-19 infections well. Many are asymptomatic, or exhibit mild respiratory or gastrointestinal symptoms, and only a minority—usually with underlying health issues such as obesity, lung disease, or heart disease—require hospitalization. Although serious or fatal infection is possible in children, the majority recover in 1-2 weeks. The considerations may be different in teenagers, which is discussed separately.
A Brief Note on MIS-C
You may have seen reports about MIS-C (Multi-System Inflammatory Syndrome in Children) which is an inflammatory syndrome that is thought to be associated with COVID-19 infection. Although little is known about MIS-C, the symptoms often overlap with Kawasaki disease, which is well known to pediatricians. MIS-C is now thought to be a result of an abnormal immune response to the virus, and occurs more frequently in older children and teens, unlike Kawasaki Syndrome. Research continues on MIS-C, but it is worth noting that it is very rare. More information can be found here, and stay tuned for an upcoming post with more details.
The Teacher Perspective
This discussion cannot focus solely on our students and ourselves. Teachers already sacrifice so much of their time and energy for our children. Many have families, and some of them are higher-risk. Individual communities and school districts will need to work with teachers and families to provide resources, including allowing those who are at higher-risk to work virtually.
Infection Rates Matter
COVID-19 infection rates vary by area. Some of this is related to population density and resources, and some of this is related to government guidelines regarding PPE/masking, opening up businesses, and public adherence to those guidelines. For those of us in Northern Virginia, we are lucky to live in an area with lower COVID-19 rates at this time, but our numbers could change at any time.
If rates remain low in your community, allowing your child more socialization opportunities and choosing in-person or hybrid options at school may be a good idea. Obviously as we approach fall and winter, local COVID-19 cases will likely increase and we all need to be able to adjust our strategy accordingly.
Let’s Be Realistic
In-person school is contingent on safety. Find out what protocols your school will have in place, and try to have a realistic sense of whether your children and their peers can adhere to distancing, hygiene, and masking guidelines.
I have been very pleasantly surprised by patients who wear masks in our office. When parents are modeling appropriate masking (wearing the mask over your nose and mouth, avoiding handling and readjusting it, and not complaining about the mask), even 3-year olds are capable of appropriate mask behavior! Be realistic, but try not to underestimate your child. Granted, they wear it only for short periods in our office, and may have a harder time wearing a mask for several hours. Practice mask-wearing and hand-washing at home! Pick masks with fun prints and colors, or get matching parent/child masks, and commit. Mask-wearing is neither political nor emotional.
Testing* and Result Turn-around Time Matter
Testing capacity in Northern VA has been disappointing. At present, when I swab someone for COVID-19 and send out the test to Quest or Labcorp, our turnaround time is 7-14 days. If my patients go to other community clinics, their turnaround time is better, but still 2-4 days, and I worry about those clinics becoming overloaded as more children require testing to clear them to return to school (and to clear their parents to return to work).
There are certainly other states with better testing capacity, Unless we have improved capability in Northern VA, what will we do when a child who attends in-person school has a fever? Quarantine their classmates and their teacher (and their families) until we have negative test results? We will have to assume any cough, or cold, or fever is COVID-19 until proven otherwise, even if many illnesses may be due to the myriad of other respiratory viruses that run rampant that time of year.
(* Note: I am referring to the swab PCR test and not the antibody test, which is challenging to interpret at this point. Although the blood test may be helpful if positive, and therefore may have a role in assessing herd immunity (even transient herd immunity), making a decision based on antibody titers is impossible because we do not know what a positive antibody titer means and how long it may confer immunity.)
Risk Matters
Many of my patients live with their grandparents, or have immunocompromised family members, or elderly nannies. For those families, in many cases it may be that the risks of in-person school outweigh the benefits, and minimizing risk where possible is likely to be worth it. Risk factors for poor outcomes from COVID-19 can be found here.
School: Thoughts on social development
Socialization is critical
School is important not just for academic learning, but for social and emotional development. Students learn to navigate peer relationships, negotiate, and work together, often guided by their teachers. This is important for their future relationships at all levels. Staying home, or going into school with guidelines such as separated desks and masking will certainly be an obstacle to social connection. You all know this, of course. And you are likely worrying that your child will end up emotionally and socially behind.
Deep breath. This is an unprecedented time. Our children are far more resilient than we believe. For many, this will be an admittedly challenging blip in their academic and social careers but they will be fine.
Because socialization is so important, whether you choose virtual learning or a hybrid approach, if it is possible I recommend trying to create a pod or a “quaranteam” with other families who have made a similar choice and whom you trust to follow guidelines and minimize risk, similar to many home-school co-ops. Allow your children to have some scheduled and consistent social time where possible, to do some group projects if age-appropriate, and keep in mind resilience and learning to cope with challenges is as important a skill as socialization.
School: Thoughts on academic development
Virtual learning is notoriously challenging for younger children. For Moonbeam*, although her school did an admirable job of offering Zoom classes and other resources, her attention span simply is not the same for learning online as it is when she is learning in person. Admittedly, the consequence on academics for Moonbeam is likely minimal because of her age.
Older children may be able to get more out of virtual learning, but if they are in school they are also more likely to adhere to the guidelines. For them, the correct decision may be dependent on how well you think they can adhere to the guidelines; this summer may be a great opportunity to get them to used to wearing a mask for longer periods in preparation for in-person classes.
Many of us rely on the expertise (and patience) of our children’s teachers; we are not equipped with the time or the resources to provide an academically rigorous experience for our children. It is overwhelming to think of our children missing out on that for an entire year, which is why I believe reassessing the situation periodically is key. It would be best for our children to have even a few months of in-person education to help mitigate what they lose out on with virtual learning.
*Moonbeam (not her real name) is our oldest child, a rising kindergartener.
Flexibility is Likely The Key
There is no perfect solution to this problem. Because the circumstances are unpredictable and rapidly evolving, reassessing the situation every 3-6 months will be helpful as we learn more about this virus. Forcing families and teachers to commit to an entire year of virtual learning (or not) minimizes the importance of teachers roles in our children’s lives. Instead, our goal should be to restore normalcy if and when possible, and rather than attacking and vilifying one another, to recognize that flexibility and resilience are the key here—and that we are all doing our best in an unprecedented circumstance.