School Health

Frequently Asked Questions about Schools Re-opening (last updated 8/9/2020)

AAP-CA2 School Health Committee

Co-Chairs: Alice Kuo, MD, PhD
Casey Nagel, MD, MPH
Nava Yeganeh, MD, MPH

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The national American Academy of Pediatrics has published its guidance on schools re-opening (https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/clinical-guidance/covid-19-planning-considerations-return-to-in-person-education-in-schools/), along with CDC (https://www.cdc.gov/coronavirus/2019-ncov/community/schools-childcare/prepare-safe-return.html?fbclid=IwAR2kNLONhmaLwsQW6QMNepFVMRlPPlnNcU5cVSxFGka02dSiTsxX4wQKdMc), California Department of Education (https://www.cde.ca.gov/ls/he/hn/documents/strongertogether.pdf), and the Los Angeles County Department of Public Health (http://publichealth.lacounty.gov/media/coronavirus/docs/protocols/Reopening_K12Schools.pdf). For schools in Los Angeles County, the Los Angeles County Department of Public Health’s guidelines are the official requirements for schools re-opening.

As students, parents, teachers, school staff and administrators tackle the complex issue of schools re-opening in the midst of the coronavirus pandemic, many have turned to their trusted pediatricians as sources of information. We have gathered the most frequently asked questions about schools re-opening from the 80+ members of our chapter’s School Health Committee and have provided answers here, with supporting scientific references when available, with the hope that this information helps all involved with this complex topic.

From Parents

  1. My child has asthma. Should they go back to in-person school?

            Having a child with asthma in a respiratory virus pandemic has raised many concerns, and unfortunately the research has not been completed yet to see how asthmatic children are doing during this time. However, many pediatricians who provide care for children with asthma indicate that asthma control has overall improved during the pandemic, and this is likely due to a combination of the fact that fewer respiratory illnesses are occurring because of safer-at-home orders and more virtual clinic visits are happening.

            Just having asthma should not stop your child returning to school, the same way that the flu season should not cause your child to remain at home. Your child should be encouraged to follow all hand-washing, mask-wearing, and physical distancing practices to ensure their safety. Also, communicate with them to report any early symptoms and make prompt virtual appointments with their healthcare provider if they are having any difficulties. If your child requires nebulizer treatments at school during the day, these treatments should be changed to a metered dose inhaler to prevent aerosolization of respiratory droplets (which protects others in the room). If your child continues to have symptoms despite being on a controller medication, you should consult with your pediatrician about other therapeutic options.

Papadopoulos NG, Custovic A, Deschildre A, et al. Impact of COVID-19 on Pediatric Asthma: Practice Adjustments and Disease Burden [published online ahead of print, 2020 Jun 17]. J Allergy Clin Immunol Pract. 2020;S2213-2198(20)30599-7. doi:10.1016/j.jaip.2020.06.001

2. My child is immunocompromised. Should they go back to in-person school?

            Having a child with a compromised immune system is (understandably) frightening during this time, and recommendations regarding returning to school should be discussed with your primary care provider and subspecialists. Research to date shows that most children who are immunocompromised and are infected with COVID-19 do well, but it depends on the degree of immunosuppression and other underlying conditions your child has (such as obesity, diabetes or a heart condition).

            Being immunocompromised should not stop your child returning to school, and you should discuss this with your pediatrician or pediatric specialist. Your child should be encouraged to follow all hand-washing, mask-wearing, and physical distancing practices to ensure their safety. Also, communicate with your child to report any early symptoms and make prompt virtual appointments with their healthcare provider if necessary.

https://www.myast.org/sites/default/files/covid-19-return-to-school-for-sot-faqs-for-families-20200727.pdf

3. Grandma or Grandpa lives with us. Should my child go back to in-person school?

Transmission of SARS-CoV-2 to an at-risk adult is a valid concern. Data to date suggest that children are infected with the virus less frequently than adults and, when infected, typically experience less severe disease. Although children have generally not been the source of disease outbreaks, it is possible that children could infect other family members after contracting SARS-CoV-2, similar to influenza virus. Because prolonged, close contact with an infected person is the main driver of transmission, the amount of contact and the specific living arrangements (separate rooms, eating spaces, etc) will likely influence risk of infection and transmission from the child to others in the household.

The answer to this question depends on multiple factors, including whether seniors in the home have chronic medical conditions and how much risk the family is able to tolerate if a student returns to in-person education. Although we know enough about how to keep people safe from COVID-19 (universal masking, social distancing, hand hygiene and sanitization), return to in-person education is not entirely risk-free. Each family will need to balance their own risks and anxiety about COVID-19 with the benefits of in-person education for children.

4. My child cannot tolerate a mask. Will you write me an exemption?

Los Angeles County Department of Public Health does not require or recommend pediatricians to write exemptions for masks. Masks are an incredibly important way for children to protect themselves from getting the virus or giving it to other children if they are already infected, and masks are absolutely safe to wear for long periods of time.

Talking openly with your child about what they don’t like about the mask can be a helpful strategy for getting them to wear it. Allowing your child to decorate their mask or use it as a part of dress-up/costume play can help them better tolerate wearing it. This is often a successful approach to children with long arm casts for example.

Early care and education settings have developed curricula for younger children on wearing masks. Some parents are reporting that their child became more tolerant to wearing masks after attending preschool and seeing other children wearing them. Children can be told that all of their friends and teachers at school will be wearing masks also.

Schools will also release guidelines on mask breaks which will be designated times where children can take their masks off (likely at certain time intervals and when appropriately physically distanced).

The California Department of Education allows for the use of face shields with a cloth drape underneath that tucks into a shirt for students who are truly unable to tolerate wearing a face mask or for children who are hearing-impaired. The Los Angeles County Department of Public Health allows for this provision in very rare instances, generally for children with special needs with significant developmental challenges.

5. Isn’t masking bad for children because they won’t be able to breathe if they wear it all day?

Masking is generally acceptable to anyone over the age of 2 years. You may know that the AAP does not recommend masks for children <2 years; this is not because of breathing issues, but rather to avoid a potential choking hazard. Masks are perhaps the most important way for children and adults to protect themselves from getting the virus or giving it to other people if they are already infected, and masks are absolutely safe to wear for long periods of time. There is no build-up of dangerous gases behind the masks when you are breathing.

            The only negative effect of masking that may need to be addressed is minor skin irritation which can be prevented by making sure the mask is properly fitted and made of a material that does not irritate your child’s skin. If they are experiencing this irritation then a gentle lotion can be used on the face and chapstick if the lips are irritated.

6. I heard that COVID-19 damages lungs. If my child gets COVID-19, will there be long-term damage to their lungs?

To date there is not enough data on the long term effects of COVID-19 on the lungs to answer this question. Children tend to have milder disease when they are infected which hopefully means that there will not be significant long term effects on the lungs or the body. COVID-19 is a part of a family of viruses called coronaviruses, and the other known coronaviruses that infect humans do not typically cause permanent long-term effects to the lungs.

7. What will be the return-to-school note process for children previously ill from COVID-19 be?

            There is no standardized return-to-school note that healthcare providers will give to families after their child has been sick. Indeed, LAC DPH does not require a note from a healthcare provider for returning to school, but individual schools may have their own policies. The current Los Angeles County Department of Public Health guidelines on when a child is safe to return to school after having been sick with COVID-19 are improving symptoms, 24 hours without fever (without using any medicines that reduce fevers for 24 hours) and at least 10 days after the onset of initial symptoms.

8. What if a school is planning to re-open without adhering to public health guidelines?

            The Governor’s order from July 17, 2020 prohibits any school in California from returning to in-person education if the county that the school is in is on the state’s monitoring list. At this time, all seven of the counties in our AAP chapter are on the state’s monitoring list. Only preschools, which fall under difference guidance for Early Care and Education, are allowed to open at this time.

            When in-person education is allowed and if you suspect that your child’s school is not adhering to LAC DPH safety and health guidelines, then we would recommend not sending your child back to that school and also to inform LAC DPH immediately.

9. I keep hearing about people with medical conditions being at higher risk for problems from COVID-19. What are these medical conditions?

There are not enough data in children to answer this question definitively. Based on available data from adult patients with COVID, children who have medical complexity, who have neurologic, genetic, metabolic conditions, or who have congenital heart disease might be at increased risk for severe illness from COVID-19 compared to other children. For the adult population, risk factors for more severe disease that have been identified are related to older age, being overweight or obese and diabetes. Children tend to have a less severe infection overall. If your child has a chronic medical condition it is prudent to make sure the condition itself is maximized (e.g., diabetic control). As well, it is always important to focus on healthy lifestyle habits to promote mental and physical wellness. Try to remain active (while staying physically distanced) and to provide your child with nutritious and balanced food.

https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html#children-underlying-conditions

10. Because my school is doing distance learning and both of us have to work, I am considering putting my child in a pod. Are there recommendations for pods?

            Learning pods are small groups of the same children that learn together in person as a substitute for the larger in-person classroom that is traditionally known. We are aware from our patients that parents are informally arranging learning pods for their children, given that all schools will be starting with distance learning this fall. We recommend that all learning pods follow the same guidelines as schools to reduce possible transmission of SARS-CoV-2. It may be more difficult to enforce infection prevention methods in a home environment as opposed to school, so following the guidelines is particularly important:

  1. In warm weather, pods meeting outdoors and socially distanced would be ideal. In the backyard or at a park would be a great location.
  2. If the pod will be meeting indoors, opening windows to improve air circulation or purchasing a HEPA filter for use in the room can decrease transmission.
  3. Limit the size of these pods to fewer than 6, or slightly more, but only if all can fit in the backyard with 3-6 feet of distance in between them.
  4. The adult and children in the pod should wear masks at all times except for when eating.
  5. If a student needs a mask break, make sure he/she is socially distanced from others during the time the mask is off.

Consider hand hygiene/sanitizing wipe-down breaks every 2-3 hours with products that can kill SARS-CoV-2 (refer to the EPA website to check: https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2-covid-19).

6. No one should be physically present if they have any potential symptoms of COVID-19. Daily symptom checking and temperature checking at home should be implemented every day.

7. If anyone in the pod develops symptoms during the school day, that person should be removed immediately and sent home.

8. If a child or adult in the pod becomes exposed to SARS-CoV-2, that person will need to be quarantined for 14 days.

Of note, parents of children in a pod need to be mindful about acquiring virus in the community and thereafter infecting the pod. Good attention to hand hygiene, masking and social distancing is critical.

11. What is this inflammatory condition that happens in kids? Should we be worried about this?

            There is a condition called multisystem inflammatory syndrome in children (MIS-C) that is a rare complication of COVID-19 infection in people under the age of 21. This syndrome happens when inflammation from the child’s immune response affects several different organs in the body. As July 31, 2020, there have only been 16 cases in Los Angeles County and fewer than 350 cases nationwide. If your child should have high fevers, rash, red eyes, and abdominal pain, vomiting, diarrhea, neck pain or fatigue, it is very important to let your pediatrician know. Currently, it appears that these symptoms happen about 2-4 weeks after initial COVID-19 infections. MIS-C is a serious condition that may require stay in the ICU, and a very few children have died. We still don’t know if there are long-term effects of MIS-C, but thus far it seems that these patients do well when they recover.

https://www.cdc.gov/coronavirus/2019-ncov/daily-life-coping/children/mis-c.html.

From Teachers

  1. I’m nervous about going back to work and being in a room with 25 students. Can they really keep me safe?

            Teachers have always been essential and important parts of our society, and the AAP will strive to see that county, state, and federal guidelines works with schools to protect them. The AAP will continue to lobby federally for increased funding for schools during this pandemic. We believe that teachers are essential workers as they educate the future of our nation. All teachers and staff should have appropriate personal protective equipment (PPE), and the in-person schooling environment should be re-designed in the safest way to prevent the transmission of COVID-19. Schools should have all the disinfectant materials, policies and protocols and classroom resources to function effectively and safely and protect all individuals (teachers, staff and students).

2. It’s difficult to communicate with a mask on all day–my students can’t hear me or read my facial expressions. Can’t I just wear a face shield (with a cloth extension)?

            Masking is the most effective way to prevent the transmission of SARS-CoV-2. Using classroom sound amplification systems which many schools have available for teachers can help if students are having difficulty understanding a teacher who is wearing a mask. Masks with a clear window for the mouth are available for teachers who are teaching hearing-impaired or other disabled students. Face shields with a cloth neck drape attached can be an alternative in rare occasions, but this method has not been as studied as have cloth face covering or masks.

3. Isn’t it better to just do distance learning until the pandemic is over?

In this ever-changing environment, it is difficult to know when the pandemic will be over, and how the world will be different after this time. In contrast, the adverse effects on children and families of virtual schooling after half a year lost are already very apparent. One in three elementary aged children have lost their ability to read and write, and most families are worried about their abilities to keep up with virtual schooling. There is also increased mental health problems for children noted by higher use of suicide hotlines. Teachers also are a common reporter of child abuse and neglect, and they cannot fulfill this role during virtual schooling. As well, many children with food insecurity depend on schools for breakfast and/or lunch. The safety and developmental well-being of our society’s children make in person schooling (when it is safe to do so) a necessity.

http://laschoolboard.org/sites/default/files/IAU%20Report%202020%200707%20-%20Student%20Engagement%20Online%20During%20Closures.pdf

4. Someone in my household has a chronic medical condition and I don’t want to bring COVID-19 home. How can I prevent this from happening?

Protecting the people you live with is very important if you could have potential exposure to SARS-CoV-2 during your work-day. Recommended physical distancing, mask wearing and potential gown and glove wearing followed by consistent use of hand sanitizer or hand washing will prevent you from contracting the virus. If you develop any symptoms, you should distance from the household member with a chronic medical condition and get a COVID-19 test.

From Schools

1. Which extracurricular activities could potentially resume if we return to in-person school?

Some activities are higher risk particularly if taking place inside, such as chorus (singing), band with wind instruments, and various sports with face-to-face contact. The nature of each activity and where it will happen will need to be taken into account before it can resume. Sports taking place outside that limit direct and persistent contact between people (such as swimming, tennis, golf) should be able to resume. Other activities that involve more contact between players need to be evaluated from an infection control standpoint.

California and Los Angeles County Departments of Public Health have guidance on youth sports, and the AAP has created an FAQ on return to sports that can be found here: https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/clinical-guidance/covid-19-interim-guidance-return-to-sports/

Recess also needs to be monitored for appropriate hand hygiene, isolated mask breaks, and appropriate physically distanced activities. Playground equipment should be sanitized after use by each cohort of students.

2. How do you manage students in Special Day Classes (e.g., who might need toileting support, or are self-injurious, or drool constantly)?

Children with special needs or disabilities will be disproportionately affected by the pandemic as their educational needs may not be sufficiently met via distance learning. When they return to in-person education, their teachers or aides may have duties that involve attending to many activities of daily living for these students. In general, a surgical mask, face shield or goggles and gloves should be worn when tending to these duties. A non-surgical gown (similar to an art smock) may be worn to protect personal clothing from potential respiratory droplets. Anything involving the bathroom or toileting with potential exposure to bodily fluid or waste should be handled with standard infection control processes (adequate hand washing/sanitization, use of chemicals to disinfect surfaces). Additionally, installing toilet seat covers can prevent virus spread if the cover is lowered while flushing. It should also be noted that paper towels are preferred over air hand dryers as the latter can forcibly drive infectious particles into the air.

For students who have 1:1 aides for part or all of the day, efforts should be made to minimize the number of exposures each adult has to each child, and vice versa. In other words, students should have the same aide and that aide would preferably not care for other students.

3. What can we do in schools to keep our teachers and staff safe?

            Universal masking, physical distancing, regular sanitizing and daily symptom and temperature checking at home is the best approach for maximizing individual safety in the school setting, including teachers and staff. In addition, teachers and staff should be able to stay home when sick and be pressured to work because of inadequate paid sick leave or other incentives to work. Teachers and staff should have an available pool of substitutes. They should also have information available as to where COVID-19 testing can be done, its likely turnaround time, and cost, when needed. Important areas of vulnerability are where adults congregate, such as common workrooms, bathrooms, and teachers’ lounges. Having thoughtful plans to prevent congregating of adults in these areas, along with cleaning protocols in between use, will help minimize transmission of SARS-CoV-2.

4. What is the effectiveness of plexiglass or other material partitions?

            According to both California and Los Angeles County guidelines for re-opening of schools, physical barriers such as sneeze guards or partitions may be useful, especially if 6 feet of social distancing cannot be observed. We would just caution that measures should be taken to clean these surfaces regularly, at least once a day and preferably multiple times a day. While Plexiglass may be an attractive option because they are clear and solid, other materials such as a shower curtain or other physical barriers can be used.

5. If students have to stay indoors, will HEPA filters help remove virus particles from the air?

Outdoor learning and activities should be pursued whenever possible, but this can be difficult for many schools and impossible in inclement weather. When learning has to take place indoors there should be special attention paid to recommendations on disinfection practices. Appropriate ventilation is also very important; most easily accomplished by simply opening all available windows and doors. Further, if possible, recycled air should be avoided (ie, it is better to exhaust air to the outside, not to other rooms) and ensuring that as much air as possible is fresh air. HEPA filters will remove SARS-CoV-2 viral particles from the air, if this is financially feasible for the school. Such filers can be used in small spaces (classrooms, bathrooms) or in-line through existing HVAC systems. Other in-line filter systems exist; consultation with facilities personnel would be advisable for individual schools. In addition, schools may consider upgrading their HVAC systems to install MERV 13 or higher filters (MERV refers to minimum efficiency reporting values). All filters should be maintained as per the manufacturers’ Instructions for Use. Finally, basic infection control practices as mentioned previously are of the utmost importance in preventing transmission.

6. One of the requirements for a waiver application to return to in-person education from Los Angeles County Department of Public Health is for a letter of support from community organizations. Would the AAP chapter be able/willing to provide a letter for our application?

Our chapter would be willing to provide a letter of support for your application. Our process would be to contact Dr. Tomas Torices, our chapter Executive Director, with your request via email (chapter2@aap-ca.org) or by calling (818) 422-9877. After reviewing your application and the local data provided by LAC DPH, we will then provide the letter of support.