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Should Kids Wear Face Masks? Suggestions from a Physician Dad

COVID-19

Should Your Kid Wear a Mask in Public?

Initially the Centers for Disease Control and Prevention (CDC) said only sick people should wear a mask in public. Last month the CDC updated its guidance and announced that all Americans should wear cloth face coverings in public to help limit the spread of COVID-19. As Tennessee and many other states begin to reopen, what do the new mask recommendations mean for children?

Healthy children over the age of 2 yo should wear cloth face covering in public.

Although public face mask recommendations are similar for all Americans over the age of 2 years old, the challenges with kids can be unique. Here are some basic guidelines to consider when facing the updated face covering guidelines and use with your children.

1. Face masks are NOT a substitute for social distancing or hand washing.

Just about every major medical and public health organization has emphasized that masks are not a substitute for social distancing. The CDC recommends that everyone wear cloth face masks in public settings where it’s not possible to stay at least six feet away from other people, like Target or your favorite grocery store.

New face covering recommendations should NOT encourage anyone to take kids unnecessarily into public settings. Social distancing should remain a priority. The most effective protection you as a parent can employ right now is to keep kids at home as much as possible, and remain diligent with good hand washing (yes --often and 20 seconds at a time...).

I tell my kids to sing Happy Birthday as they wash their hands - but just not too fast. It usually is the 20 to 25 seconds needed for good hand washing. - Cory Calendine MD

In general, masks are for when you have to go out and there is a chance that you may not be able to fully maintain at least six feet of physical distance from others. If your child is outdoors for a walk or playing in an area where they can remain six feet away from other non-household members, a face covering is not needed. Non-medical face coverings are recommended for those necessary trips out to the grocery store or pharmacy. Even at those times (and even when wearing a face covering), every effort should be made to stay at least six feet from others to minimize the  spread COVID-19.

2. Children are champion asymptomatic virus spreaders.

There’s mounting evidence that many kids are asymptomatic carriers of coronavirus and get mild (or no) symptoms of COVID-19 and can unwittingly spread the disease. In addition, non-medical cloth masks function mainly to eliminate respiratory droplet spread from the person wearing the mask. Cloth masks are up to three times less effective at filtering the tiny airborne virus particles that can be spread by others. Therefore, cloth masks for kids are designed to protect others (not those wearing the masks).

Covering your child’s face will help prevent them from spreading respiratory droplets with coronavirus into the air, whether they seem sick or not. Since so many asymptomatic COVID-19 cases appear to occur in children, the director of the CDC recently told NPR that all children should wear masks in public “because they’re probably the ones who are shedding the virus (to others).”

Dr. Deborah Gilboa, a family physician and youth development speaker, in an interview with TODAY Parents, discussed why healthy children should wear masks when possible.

Kids are much more likely to be asymptotic or pre-symptomatic carriers, so we do a lot of good when we say, “Hey, in addition to washing your hands, and please stop licking things, we'd also like you to wear a mask.” We really want to slow and stop the spread of this, and we're seeing in data from other countries that kids are actively involved, entirely accidentally, in spreading this (COVID-19).

3. No masks for kids under the age of 2 and not for babies (no matter how cute of an Instagram pic it makes).

The CDC and American Academy of Pediatrics (AAP) recommendations specify that face masks and cloth face coverings should not be placed on any child younger than 2 or any child with severe cognitive or respiratory impairments . In general, caution should be used to insure a child's face covering does not pose a choking or suffocation hazard. Babies’ airways are smaller and breathing through a mask could cause them breathing difficulty. When a mask impedes a child’s ability to breathe normally, or when the child is unable to remove the mask on their own if needed, a face covering should not be worn.

Nationwide Children's Hospital suggests that a blanket covering placed over an infant’s carrier can provide some protection from potential pathogens while allowing the baby to breathe comfortably. Still, parents who must go into public with young children should keep their trips as short as possible and maintain six feet of social distance. A recent study of more than 2,500 children with COVID-19 found that infants are more likely to be hospitalized with more severe disease than older children.  

https://www.buybuybaby.com/store/product/itzy-ritzy-peek-a-boo-pod-infant-carrier-pod-in-rodeo/1040054483

Although experts agree there are very good reasons for children older than 2 to wear masks in public, there are times that young kids and masks will be a “no-go”.

The likelihood that toddlers will always, 1) keep masks on their little faces for a quick trip to the store, and 2) do so without constantly touching them --- is basically zero. Parents will have to choose their battles. There are times you may do far more to protect your kids by trying to curb those natural tendencies to lick and touch every surface and, of course, by being diligent with social distancing.

It is important to note that a face covering can be distracting to children and cause them to touch their face more than usual. Guidance from the American Academy of Pediatrics available suggests reconsidering the use of a face mask when it causes your child to touch their face more frequently than when they are not wearing it. You know your child the best and sometimes have to simply rely on your best judgement.

4. Healthy Kids should use basic (inexpensive) cloth masks.

Homemade or purchased cloth masks are fine for most kids to wear. The CDC and AAP agree that face coverings should be made from "simple cloth ... fashioned from household items or made at home from common materials." Although medical masks are far superior at filtering airborne viral particles, surgical masks and N-95 respirators should be reserved for healthcare workers/medical first responders and not be used by the general public (exceptions outlined #6 below).

If you are making a mask for your kids,  it's okay to do the best with what you have on hand at home. The CDC outlines that cloth coverings should:

  • fit snugly but comfortably against the side of the face
  • be secured with ties or ear loops
  • include multiple layers of fabric
  • allow for breathing without restriction
  • be able to be laundered and machine dried without damage or change to shape

For children, the correct fit of the mask may be challenging. Pleated face coverings with elastic are likely to work best for most kids. Adult face masks (usually 6x12 inches), and even a child-sized (5x10 inch) covering may be too large for smaller children. Try to find the best size for your child's face and be sure to adjust it for a secure and comfortable fit.

A recent study by Smart Air rated the best materials to use for homemade face covering based on their ability to filter coronavirus-sized microparticles, as well as their breathability. Based on these criteria, the study recommended denim, bed sheets (80-120 thread count), paper towels, canvas (0.4-0.5mm thick) and shop towels for the best homemade masks. Whichever material you choose to make your child’s mask from, face coverings are not guaranteed protection from COVID-19. DIY face mask are recommended in public settings where you cannot always stay six feet away from others, but masks are not a replacement for social distancing.

**Dr. Jerome Adams, US Surgeon General, How To Make Your Own Face Covering. Source: CDC.gov

RELATED: Download CDC DIY Cloth Face Covering Instructions PDF

5. Have your child practice at home first. Practice, practice, practice.

Try to resist the urge to assume that your child is going to respond negatively to wearing a mask.

Introduce the idea and ask them what they think. They may be excited about wearing a mask with a fun pattern or their favorite color. Or they may be a fan of more famous face mask advocates (Spiderman, Iron Man, Batman, Wolverine). Regardless, it will be helpful to give them an opportunity to practice wearing a mask at home and watch you model wearing your non-medical face covering so they can get used to it.

Once a child has learned to keep a mask on their face,you need to make sure they understand that they have to try not to touch it.For most kids, this will take practice (and for parents, PATIENCE). Joy Kawamura, a psychologist with Seattle Children’s Hospital suggests practicing with specific steps:

How are we going to put the mask on? What do you do with your hands? At some point, you’re probably going to see restlessness kick-in, and that’s when it’s important that you’re there to remind your kiddo to resist the urge to touch their mask or their face. Explain that they will need to wash their hands before they touch their mask and after —every single time.

With repetition and practice at home, even young children will become more comfortable with healthy habits such as wearing a mask and frequent washing hands. Establishing consistent routines, rehearsing and reviewing what will happen next, and giving children enough time to adjust between activities can all help children with mastery and reduce their level of anxiety with these new experiences.

For teaching the importance of face masks, the American Academy of Pediatrics (AAP) recommends focusing on germs. Explain that some germs are good and some are bad --- and they should not be shared. The bad ones can make you sick. Since we can't always tell which are good or bad, the cloth face coverings help make sure you keep those germs away from your own body. Other strategies from AAP for calming face mask fears in kids include:

  • Look in the mirror with the face coverings on and talk about it.
  • Put a cloth face covering on a favorite stuffed animal.
  • Decorate them so they're more personalized and fun.
  • Show your child pictures of other children wearing them.
  • Draw one on their favorite book character.
RELATED: Resources from the American Academy of Pediatrics (AAP):

6.  Some kids need additional COVID-19 protection. Children with chronic disease, immune deficiency or acute illness require additional precautions.

  • Children who are considered high-risk or severely immunocompromised are encouraged to wear an N95 mask for protection.
  • Families of children at higher risk are encouraged to use a standard surgical mask (at the least) if they are sick to prevent the spread of illness to others.
  • Children with severe cognitive or respiratory impairments may have a hard time tolerating a cloth face covering. For these children, special precautions may be needed.
  • Again, No face coverings should be used in infants under 2 years old.

If your child is sick with mild symptoms that you are able to manage at home, you should call your child’s healthcare provider to discuss the specific circumstances surrounding their illness and the symptoms they are experiencing. This way, your child’s healthcare provider can give specific recommendations for your child and can make recommendations about whether your child should be seen in person for care, whether a video visit or telehealth visit could be used, or whether a specific treatment would be recommended based on the illness symptoms your child has.

Calling your child’s medical provider with questions or for guidance can help insure your child gets the care they need in the right location and with the most appropriate precautions in place to prevent risk of exposure or transmission of COVID-19.

Like the Bone and Joint Institute of Tennessee, many medical practices have instituted specific COVID-19 screening policies and expanded Telehealth video visit options. See a brief video on our offerings below.

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Cory Calendine, MD is an Orthopaedic Surgeon and founding partner of the Bone and Joint Institute of Tennessee at Williamson County Hospital in Franklin, TN. Dr. Calendine is an expert in Joint Replacement, specializing in Hip and Knee Surgery. From diagnosis through treatment, the Orthopaedic Surgical experts at the Bone and Joint Institute use the latest techniques and technology to improve care for people with musculoskeletal problems. For more information, please contact our office or schedule your appointment today.  
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