Dear Colleagues,
With the start of the school year, we anticipate many questions from our patients and their parents about the safety of returning to school, the impact of COVID19 on children, and requests for mask exemptions. As physicians, we are a trusted source of science-based medical information and must help our patients navigate the mixed messages they are getting from various sources. We want to provide you with the information you need to have these important conversations.
Should children return to school?
In general, yes. The benefits of in-person education have been well-documented and discussed extensively, and these outweigh the risk of COVID infection for most children. For medically complex children and immunocompromised children, the conversation should be individualized. For those with a higher risk of infection or risk of severe outcome with infection, an N95 mask may be the best choice to allow them to return to school safely.
Safety in schools is maximized when those who are 12 and older are vaccinated, social distancing is maintained, and masks are utilized properly by everyone. With the Delta variant being predominant in our area, even vaccinated persons are susceptible to infection and if infected, may spread the infection to others.
Children and COVID-19
We must recognize that much of the attention around COVID disease has been focused on adults. You may be the only one to talk to the family about the risk to children from COVID infection. Although children generally have good outcomes following infection, some children will be significantly ill. Most children who have become hospitalized from COVID (a number which, unfortunately, is growing rapidly during the current national surge in case rates) develop pulmonary syndromes similar to adults. However, one risk specific to children is the post-infectious syndrome MIS-C (multisystem inflammatory syndrome in children). This syndrome, by definition, is severe enough to warrant hospitalization. Locally, more than 90 children have been hospitalized at Valley Children’s Hospital, and the majority needed ICU-level care.
The COVID-19 vaccine and kids
The current vaccine licensed for children (Pfizer, ages 12 and older) is safe and effective for preventing severe disease, hospitalization and death, and should be encouraged for all eligible children to make the return to school as safe as possible. There is no longer a wait period of two weeks between any COVID vaccine and other vaccines, which can be given concurrently. This change is important because many children have fallen behind on routine vaccinations and every opportunity should be utilized to get these children back on schedule.
Medical exemption requests
You may be asked to provide a medical exemption for a child to allow them to return to school without masking. Almost all school-age children can and should wear a face mask, which is recommended by both the Centers for Disease Control and Prevention (CDC) and American Academy of Pediatrics (AAP) and required for in-person classroom instruction by California Department of Public Health (CDPH). A medical exemption would be appropriate for some children with diagnosable cognitive disabilities or a medical condition for whom wearing a mask for an extended period of time could obstruct breathing, or who are incapacitated or otherwise unable to remove a mask without assistance. This would also be appropriate for children who are hearing impaired, where the ability to see the mouth is essential for communication. If a child is unable to use a close-fitting mask, a face shield with a drape is required. If a child has a medical contraindication to both these options, the exemption form should specify that.
For those children with a mask or mask/shield exemptions, other measures such as frequent hand hygiene and social distancing are especially important. Not every cognitive disability or lung disease will qualify for an exemption. Neither asthma nor ADHD, very common pediatric diagnoses, would qualify for medical exemptions. This may be a difficult conversation, so you should be prepared for some resistance. Here is the CDPH Guidance on face mask exemptions, for your reference:
Assessing for exemption due to a medical condition, mental health condition, disability that prevents wearing a mask, or hearing impairment is a medical determination and therefore must be made by a physician, nurse practitioner, or other licensed medical professional practicing under the license of a physician. Self-attestation and parental attestation for mask exemptions due to the aforementioned conditions do not constitute medical determinations. Additionally, per CDPH K-12 Guidance, "persons exempted from wearing a face covering due to a medical condition, must wear a non-restrictive alternative, such as a face shield with a drape on the bottom edge, as long as their condition permits it."
