As many of our patients get ready to return to school, parents have questions regarding safety and possibility of exposure and infection for their children, and also for the rest of the family. Parents are coming to us for guidance, and unfortunately, at this time there are no formal guidelines to follow.

The following is to serve as general information that we can consider and share with our patient’s parents to help them with the decision to allow or not their children return to the classroom. Remember this is a changing situation and our advice will likely change once more information becomes available.

Regarding the Schools

Schools should be formulating and be ready to implement safety actions to follow once schools re-open. “ As schools reopen, they should follow CDC recommendations on cleaning and disinfecting and consider phased reopening, staggered scheduling and social distancing protocols. Plans also should be in place for excluding and isolating sick children and staff. Even with these measures in place, some students with high-risk medical conditions may need to continue distance learning”
Teachers and other adults in the school setting can be a source of infection for the children. Teachers should strictly adhere to social distancing among themselves such as no in-person meetings, and limit use of teacher lounge areas, followed by frequent disinfection.
Parents in person participation in school activities should be limited
SARS CoV-2 transmission and risk of infection in pediatrics

Some data show that children are not the primary source for SARS CoV-2 infection, but children have become infected after exposure to infected adults. A study published in Pediatrics showed that 73% of the time, parents had symptoms before children, and in only 8% of the time, the child had symptoms first.
If exposed to COVID-19, children may be less likely to become infected. In a study from China looking at 105 index cases (all adults) with 392 household contacts that were swabbed 2-4 times for SARS-CoV2 via RT-PCR, found a child infected in 4 instances with a secondary attack rate of 4% in children (2.3% <5 yo), compared to an attack rate of 20% in adults.
Some studies have also shown that there may be a lower prevalence of COVID-19 among children than adults, but what is unknown if this will change once children face increased exposure after schools re-open. It is important to remind our parents that so far children at large have had mild disease presentations compared to adults.
“Based on data at this time, transmission from students to staff and from students to other students (especially younger students) appears to be rare, and will likely be even more rare with appropriate risk mitigation strategies. Attention to prevention of staff-to-staff transmission is critical. However, most contact tracing studies have been conducted in the setting of low community prevalence of COVID-19.” This might be different in our community with increasing prevalence of SARS CoV-2.
For consideration, until more data or guidelines becomes available

Parents should ask the school to share the preparedness plan (number of students in the classroom; plan for lunch, recess and passing/pathways in halls). Schools should follow the CDC guidance on school reopening.
Parents should remind the children to practice hand hygiene, not to share personal items, and teach them to try to avoid touching their faces. Encourage them to use face covering as recommended by the CDC.
Parents of children with underlying chronic lung disease, pulmonary insufficiency, severe asthma should strongly consider distant learning.
Parents of children with underlying immunodeficiencies (primary and secondary), the decision to attend school in person, should be guided by the nature of immunodeficiency. Parents should work closely with their doctor/Immunologist and school to develop an individualized plan.
Healthy siblings of children with underlying medical issues should be able to attend school in person, but parents should be diligent in hand hygiene immediately after returning home.
Children with febrile illness, respiratory or gastrointestinal illnesses, should be excluded from schools.
Students sent home with suspected COVID, must remain home 3 days with no fever and respiratory symptoms have improved (e.g. cough, shortness of breath) and 10 days since symptoms first appeared.
A child who has close contact with someone with COVID-19 should stay home for 14 days after exposure based on the time it takes to develop illness.
Parents should be encouraged to keep appointments for their children’s immunizations. This year Influenza vaccination will be critical.
Unknown

Will we see an increase in MIS-C cases?
Is there a role for routine testing in school settings? How often?
Children can become infected with SARS CoV-2, they can shed the virus, but shedding does not equate transmission. Will this be different now that COVID incidence is higher in our community? Will viral load among children increase, making them more likely to transmit the virus?

Many of us have experienced or read about increasing mental health needs during the COVID pandemic.

References:

https://www.aappublications.org/news/2020/06/26/schoolreopening062620

https://pediatrics.aappublications.org/content/pediatrics/early/2020/05/22/peds.2020-1576.full.pdf

https://doi.org/10.1093/cid/ciaa450

https://primaryimmune.org/video/children-covid-19-back-school-idf-forum-june-23-2020