Evidence of transmission and mask use among children

Children, defined here as anyone less than 18 years old, can be infected with SARS-CoV-2 and transmit it to others. Between 1 - 7% of confirmed COVID-19 cases have been reported among children (Study 1, Study 2, Study 3, Study 4). As children tend to have less severe COVID-19 symptoms than adults, case-based reports of COVID-19 may underestimate the true prevalence of infection among children. The amount and duration of SARS-CoV-2 shedding among children is incompletely characterised with several studies reporting differing results (Study 1, Study 2, unpublished study 3). The effect of age on transmission, and therefore the contribution of children to global COVID-19 transmission, is not well understood.

Currently, there are no studies of the effectiveness of mask use among children in limiting COVID-19 transmission. There is limited evidence that mask use may reduce influenza transmission among school-aged children, particularly when used soon after symptom onset, though other studies have found no effect. Mask effectiveness may be influenced by acceptability and consistent use which have been shown to be highly variable among children (Study 1, Study 2, Study 3, Study 4, Study 5). Factors such as age, duration of use, and discomfort may impact acceptability and use.

Recommendations for fabric mask use among children in community settings

Given the limited available evidence on the effectiveness of masks to reduce or prevent transmission of COVID-19 among children, the WHO suggests that mask use policies be driven by three “overarching guiding principles”:

  • Do no harm. Prioritize the health, well-being, and best interests of children.
  • Avoid policies that may have a negative impact on development or learning outcomes.
  • Policies should consider the feasibility of implementation in different contexts, including consideration of social, cultural, and geographics norms, availability of resources, setting type (e.g. humanitarian), and special needs groups (e.g. those with disabilities or specific health conditions).

In areas where community transmission is ongoing and physical distancing is difficult, the WHO has provided the following recommendations regarding mask use among children:

  1. Children aged five years or younger should not wear masks for source control. If national policy dictates that children younger than five are required to wear masks, the WHO recommends that those children are under constant supervision to ensure child safety and proper mask use. Under no circumstances should children younger than five with severe cognitive or respiratory challenges be required to wear masks.
  2. A risk-based approach should be used to decide whether children aged six to 11 years of age should wear masks. The approach should consider the following: (1) the amount of community transmission in the area and any newly available evidence on risk of transmission among children aged 6 - 11 years; (2) any social and cultural beliefs, customs, behaviors or other norms that influence interactions with and among children; (3) the child’s ability to appropriately use the mask and the availability of adult supervision; (4) the potential implications of mask wearing on learning and psychosocial development; and (5) adaptations for specific settings including schools, sporting events, or when there is potential for exposure to vulnerable populations such as the elderly or those with underlying disease or disability).
  3. Children aged 12 years or older should follow WHO or national guidance for mask use in adults. For these children, mask use may not be recommended in certain circumstances or settings, as described below.
  4. Decisions about mask use for children with certain health conditions, diseases, disabilities, or developmental disorders should be made in consultation with a medical provider. Mask use is typically recommended for children who are immunocompromised or have been diagnosed with cystic fibrosis or cancer. Mask use should not be mandatory for children with developmental disorders, disabilities, or other health conditions but rather be decided on a case by case basis.

Considerations for mask use in specific circumstances and settings

  • Children with disabilities or developmental disorders: Mask use should not be required for children with disabilities or developmental disorders. These children should be given alternative options such as wearing face shields. Adults working with children with disabilities who require close physical contact should wear masks and adhere to other infection prevention and control measures such as frequent hand hygiene. Widespread mask use, coupled with physical distancing, may pose challenges for children with hearing problems who rely on lipreading or facial expressions to communicate. In these cases, families, educators, and others may consider using face shields or masks with clear panels to allow for lipreading. The below photo depicts a fabric mask with a clear panel in front.

Source: Jakarta Post

  • Mask use in schools: School mask policies should consider a) the age-related WHO recommendations for mask use among children, b) how the mask policy fits within a broader infection prevention and control strategy (e.g. hand hygiene, physical distancing), and c) the thoughts of educators who may have to balance the advantages of mask use against its potential burden on learning and other school activities. For additional information on the use of masks in schools please see this resource ‘Promoting good respiratory hygiene practices’.

Implementation Considerations for Child Mask Use Policy

Communication: Communication materials explaining the purpose and use of masks should be adapted to be context-specific and age-appropriate for children and should remain flexible to changes in evidence, community needs, and feedback or questions from children. Parents/guardians, educators, and trusted community members and leaders should communicate the importance and safe use of masks to children through role-modelling. Messaging to children should emphasize the role of masks as one part of a broader infection prevention and control strategy to ensure mask use does not result in children feeling a false sense of security and disregarding other preventative measures.

Mask design and use: Mask design should consider the quality, breathability, fit, and comfort of the child. As acceptability among children may be a barrier to use, masks should be child-friendly and be made in a variety of sizes, colours and designs. For more information on the design features of fabric masks, please see this resource. Strategies to assist children in the safe use of masks should be considered. This includes providing for the safe storage of used masks for reuse (e.g. following eating, exercise) or for eventual laundering. Children may require use of several masks over the course of a day as they become soiled, wet, or lost.

Accessibility: Ensuring equitable access to masks among children is important and access must not be a barrier to use. Masks should be accessible free of charge to children living in limited resource settings.

Alternatives to masks: Some children may have difficulty wearing a mask due to disabilities, health issues, or other reasons. The WHO suggests the use of face shields in these circumstances. Face shields may provide some protection from respiratory droplets, though large gaps between the shield and face may limit effectiveness. There is currently no evidence on the use of face shields for source control. For these reasons, face shields should not be considered equivalent to masks in terms of protection or source control but they are suggested as an alternative for children who may not be able to wear masks. If face shields are to be used, the following precautions and use instructions should be implemented:

  • As face shields offer only partial protection, physical distancing, hand hygiene, and other infection prevention and control strategies remain important.
  • The face shield should wrap around the sides of the face and extend below the chin.
  • Face shields should be cleaned with soap and water and disinfected with ≥70% ethanol after each use.
  • Children should be instructed on how to safely put on, take off, and wear face shields to avoid injury during use.

Monitoring and evaluation: Given limited evidence of face mask use among children, the WHO recommends setting up monitoring and evaluation programs to assess the impact of masks on child physical and mental health. Key indicators should include impact on COVID-19 transmission, acceptability, use, and barriers of mask use, and potential effects on learning, development, and school attendance. The impact on children with special needs should be given specific attention. For more information on monitoring evaluation, please see this WHO document.

Want to learn more about mask use for interrupting the spread of COVID-19?

Editor's note

Author: Jackie Knee
Review: Peter Winch, Julie Watson
Last update: 10.09.2020


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