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It’s July 2020. We’ve been experiencing the COVID-19 pandemic for 4 months. With schools scheduled to open in 6-8 weeks, it’s a tragedy that we haven’t gotten this virus under control, at least enough control to consider schools to be safe. Recently, the American Academy of Pediatrics released this statement on why they believe in-person school is more beneficial to children than distance learning, and offers suggestions for making it safe. In a risk v benefit scenario, for most children, the benefit of in-person learning, services provided, socialization and nutritional support outweighs the risk of disease given that current data suggest that children are not the primary source of spread. Of course this is assuming lots of modifications to mitigate the spread of coronavirus, especially to teachers and staff. School districts will need to consider the concerns of pediatricians while also following CDC guidelines for safe opening in order to make their plan for the coming school year. However, not everyone is on board with this. Here are some of the arguments.

Are pediatricians equipped to weigh risks and benefits of school opening?

This question was posed to me on Twitter and needless to say, I was shocked. Who else is better at understanding the physical and mental well-being of children than pediatricians? Furthermore, the statement is not a hard and fast policy but gives guidelines to assist schools in their decision making. The AAP has always been first and foremost a strong advocate for the physical, mental and social well being of children from birth through their teen years. This includes an entire section dedicated to school health. Here are some things we do as pediatricians to care for school aged children that specifically applies to school related issues.•We are asked to clear students for school attendance and for school sports as part of routine care.

•We are regularly asked to assess children who have issues in school with learning difficulties, bullying, ADHD, anxiety and depression. Sometimes we pick up these issues during well care but often children are sent to us from the schools themselves for evaluation. You can see my post on that here.

•We have remained open and on the front line during the pandemic, frequently addressing the concerns of children and their parents with regards to distance learning.

What have been the negative unintended consequences of distance learning?

To be clear, none of us (including the AAP who has provided extensive guidance to us about COVID) have denied the existence of the SARS-COV2 pandemic. Back in March it was necessary to close schools in order to mitigate spread of the virus, especially because we didn’t have a lot of details on exactly how it was spread. As pediatricians, I supported that. Since that time, pediatricians across the country have seen children with a variety of issues related to distance learning. I have personally seen a range of reactions from those loving the freedom and flexibility to those with severe anxiety and depression. Some families gave up school all together because every child at home had 8-9 logins for different learning platforms that they could never remember. The concerns mentioned in the AAP statement have been a reality for many families and pediatricians have attested to this. Without school (not including homeschooling for which families are prepared and set up for), children have missed out on a lot of their learning and have experienced other unintended consequences.

• Due to a variety of issues including access to supplies and internet, the learning gaps for children in lower socioeconomic environments may become larger.
•Parents have had to work full time, as well as teach their children. This can cause a lot of family stress. Many of these parents will have to return to the workplace as more businesses open, leaving children in someone else’s care (assuming they have the resources to do so) to provide their distance learning if that continues next year.
•Children who rely on school lunches for nutrition have had to rely on other sources of food.
•Children with special needs have missed out on the services they receive through the school. This includes much needed therapies for children with autism.
•Many children have developed mental health concerns due to the social isolation, along with the missed activities and milestones.
•We’ve seen an increase in obesity due to decreased physical activity.
•We’ve even seen a decrease in abuse reporting, not because it isn’t occurring but because teachers are overwhelmingly the first to notice when abuse happens.

These learning, mental and physical health concerns can not be discounted when deciding how to provide all of the resources schools provide to students this coming school year.

Is it safe for students to return to school?

If you’ve read this far, hopefully you can agree that pediatricians are very much equipped to help make a statement regarding school opening and you can understand why we think in-person learning should be the goal. Of course every community and school district will have to consider their current spread of SARS-COV2 to assess their own ability to safely open schools. Furthermore, the AAP statement is clear that there is no one-size-fits-all plan. Schools will need to be flexible for high risk students and teachers. They will also need to be prepared for closures again if needed.

Now that we are 4 months into this pandemic, we have a lot more data on how the virus spreads and the risk to the pediatric population specifically. Unlike influenza or other viruses, SARS-COV2 does not disproportionately affect children. They get sick less often and have milder illness. Milder illness means less risk of spread without as much coughing or sneezing or wiping at the nose. Furthermore, outbreaks for the most part have not started with children. This review looks at children who stayed in preschool and daycare during lockdown, with mitigation efforts in place. None of them got sick. With significant changes, it seems children can safely be in school.

Schools should consider the following:

•Screening students for symptoms
•Clustering younger aged children
•Sanitizing surfaces regularly
•Having readily available hand sanitizer

•Requiring masks for children old enough to wear them
•Keeping students distanced in the hallway
•Not allowing students to share supplies
•Keeping teachers from congregating for meetings or in break rooms.

Of course this takes a lot of resources, something local governments will need to consider and should be currently planning for. They should also maintain the option of distance learning for children and teachers who are at high risk or who are medically fragile. Improving distance learning will also take resources to be sure everyone has the equipment and internet access needed.

What effect will summer have?

With lots of places flattening the curve during spring, businesses, workplaces, daycare centers and camps have begun to open. Unfortunately, they opened without a national mitigation plan that would provide testing, tracing, isolation of contacts and of course a mask mandate. Furthermore, places opened that probably should not have, like bars and churches. Consider how this virus is mostly spread: the virus is housed in respiratory droplets that come from your nose and mouth when you speak, laugh, sing, cough or sneeze. Now consider an indoor environment in which people who are not wearing masks are clustered closely together talking, laughing or singing. This is how people get sick and outbreaks get started. Indoors is less safe than outdoors because there is less air flow carrying respiratory particles away from our mouths. Many clusters and outbreaks of late have occurred because people are gathering in these close contact environments; in their homes, having parties, weddings and sleepovers, going to bars. So will this ruin any prospect for in-person learning in the fall? I hope not. As this article points out, if states can open bars, where SARS-COV2 spreads easily, without considering how schools will open safely, they need to check their priorities. For now, I know that lots of kids are back in daycare, going to camp, hanging out with their friends on the beach, going to a neighbors to swim, resuming sports practice and generally returning to pre-COVID socializing. Many of these activities are outside, which is safer than being inside so it remains to be seen what will occur in the pediatric population over the next few weeks. Especially because many safety measures have been put in place for those camps and daycare centers. Does it make sense that once fall comes around we should separate them all again, force them in their homes and resume a less than optimal educational experience?

If hospitals, daycare centers and workplaces can control their environment to reduce spread, schools can put measures in place to do the same. After all, if parents are going back to work, children will need to be in some sort of care and school is the optimal place. With screening, testing, masks, sanitizing and distancing, children, who are at decreased risk from COVID and who are less likely to spread it anyway, should be able to return to the classroom. High risk children and families should still have the option for distance learning and this option should be prioritized for high risk teachers. This doesn’t mean schools will be zero risk, but for the vast majority of children, the risk of not being in school may be higher. Hopefully, people gathering at parties or going to bars doesn’t ruin it for them.

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