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CME / ABIM MOC / CE

What Are the Public Health Policy Implications of Child Masking?

  • Authors: News Author: Marcia Frellick; CME Author: Laurie Barclay, MD
  • CME / ABIM MOC / CE Released: 3/11/2022
  • Valid for credit through: 3/11/2023
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  • Credits Available

    Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 0.25 ABIM MOC points

    Nurses - 0.25 ANCC Contact Hour(s) (0 contact hours are in the area of pharmacology)

    Pharmacists - 0.25 Knowledge-based ACPE (0.025 CEUs)

    IPCE - 0.25 Interprofessional Continuing Education (IPCE) credit

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    • Letter of Completion
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Target Audience and Goal Statement

This activity is intended for pediatricians, family medicine clinicians, nurses, pharmacists, primary care clinicians, public health officials, and other members of the healthcare team involved in counseling regarding use of masks in children to help prevent COVID-19.

The goal of this activity is to describe the association between masking children aged ≥ 2 years and subsequent childcare closure because of COVID-19, according to a prospective, 1-year, longitudinal electronic survey study of 6654 childcare professionals at home- and center-based childcare programs in all 50 states.

Upon completion of this activity, participants will:

  • Describe the association between masking children aged ≥ 2 years and subsequent childcare closure because of COVID-19, according to a prospective, 1-year, longitudinal electronic survey study
  • Determine public health implications of the association between masking children aged ≥ 2 years and subsequent childcare closure because of COVID-19, according to a prospective, 1-year, longitudinal electronic survey study
  • Outline implications for the healthcare team


Disclosures

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All relevant financial relationships for anyone with the ability to control the content of this educational activity are listed below and have been mitigated according to Medscape policies. Others involved in the planning of this activity have no relevant financial relationships.


News Author

  • Marcia Frellick

    Freelance writer, Medscape

    Disclosures

    Disclosure: Marcia Frellick has disclosed no relevant financial relationships.

CME Author

  • Laurie Barclay, MD

    Freelance writer and reviewer
    Medscape, LLC

    Disclosures

    Disclosure: Laurie Barclay, MD, has disclosed the following relevant financial relationships:
    Stock, stock options, or bonds from: AbbVie Inc. (former)

Editor/CME Reviewer/Nurse Planner

  • Leigh A. Schmidt, MSN, RN, CMSRN, CNE, CHCP

    Associate Director, Accreditation and Compliance
    Medscape, LLC

    Disclosures

    Disclosure: Leigh A. Schmidt, MSN, RN, CMSRN, CNE, CHCP, has disclosed no relevant financial relationships.

CME/CE Reviewer

  • Yaisanet Oyola, MD

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Disclosure: Yaisanet Oyola, MD, has no relevant financial relationships.


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CME / ABIM MOC / CE

What Are the Public Health Policy Implications of Child Masking?

Authors: News Author: Marcia Frellick; CME Author: Laurie Barclay, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 3/11/2022

Valid for credit through: 3/11/2023

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Note: The information on the coronavirus outbreak is continually evolving. The content within this activity serves as a historical reference to the information that was available at the time of this publication. We continue to add to the collection of activities on this subject as new information becomes available. It is the policy of Medscape Education to avoid the mention of brand names or specific manufacturers in accredited educational activities. However, manufacturer names related to COVID-19 vaccines may be provided in this activity to promote clarity. The use of manufacturer names should not be viewed as an endorsement by Medscape of any specific product or manufacturer.

Clinical Context

It is now known that face masks reduce SARS-CoV-2 respiratory droplet transmission in the community and high-risk environments. A current study by Murray and colleagues shows that in schools, masks successfully mitigate risk, facilitating safe return to in-person education. This new data has major public health policy implications for caregivers and parents who depend on reliable childcare programs for their ability to maintain employment. In the current environment of masking debates, this study can be used to support masking as a mitigation strategy and can provide members of the healthcare team with evidence-based guidance for parents, caregivers, and other childcare professionals who may have concerns.

Study Synopsis and Perspective

Mask-wearing in childcare programs is linked with fewer COVID-19–related program closures, new data released suggest.

Researchers included 6654 childcare professionals in a prospective, 1-year, longitudinal electronic survey study of home- and center-based childcare programs in all 50 states.

Findings by Thomas S. Murray, MD, PhD, with the department of pediatrics, Yale University, New Haven, Connecticut, and coauthors, were published in JAMA Network Open on January 28.[1]

They found that mask-wearing from the May 22, 2020 baseline to June 8, 2020 was associated with a 13% reduction in program closures within the following year (adjusted relative risk aRR = 0.87 [95% CI: 0.77, 0.99]). Continued mask-wearing throughout the 1-year follow-up was associated with a 14% reduction in program closures (aRR = 0.86 [95% CI: 0.74, 1]).

The authors said the evidence supports current masking recommendation in younger children provided by the Centers for Disease Control and Prevention (CDC).

They wrote, “This finding has important public health policy implications for families that rely on childcare to sustain employment.”

The benefits of masking in preventing COVID-19 transmission within kindergarten through 12th grade classes are well documented. Masks are particularly important in areas where vaccinations are not widespread.

Masks can be worn safely by young children without harming respiratory function, studies have shown.

William Schaffner, MD, an infectious disease expert at Vanderbilt University, Nashville, Tennessee, pointed out that the American Academy of Pediatrics has said there are no noteworthy effects on breathing function for most children.

“There’s been so much discussion about the contribution of masks to reducing the risk of COVID that it’s nice to have the data,” he said, adding that this is a relationship that has been difficult to study, but this analysis was able to make the connection with hard numbers.

“It’s an important outcome,” he said in an interview.

The authors pointed out there is evidence that school-age children can identify most emotions in masked faces.[2]

They added that “2-year-old children recognize spoken words better through an opaque mask, compared with a clear face shield, suggesting verbal communication to infants is not harmed by face masks.”

Studies have shown that childhood infection with other respiratory viruses also decreased and asthma symptoms were not reported when preschool children wore masks and used other preventative steps.

The authors wrote that a potential reason for that may be that those who wear masks have less face touching, known to increase the spread of COVID-19.

Paloma Beamer, PhD, an engineer and exposure scientist at University of Arizona, Tucson, Arizona, who also has a 3-year-old son who wears masks at his daycare center, said in an interview that she works closely with his school on training kids how to wear their masks because getting young children to keep them on and finding ones that fit is challenging.

“We need layered controls and protections in place at schools as much as possible,” she said, adding that the authors didn’t mention ventilation, but that’s another important component as well.

“We’re fortunate in Arizona that we are in an old school and the windows are open as much as possible,” she said.

She said this study shows that “masks are a great form of additional control.”

Her son is on his third quarantine this month after 3 kids tested positive, she added.

She said, “I think these newer variants perhaps make the findings of this study more compelling and it will be interesting to see if the researchers do a follow-up study.”

Strengths of the study include that it used prospective data from a large national cohort of childcare professionals. In addition, the retention rate was high at 1 year, and the self-reported information likely gives better information than looking at policies that may or may not be well followed.

Limitations include potential reporting bias because the self-reports were not independently confirmed. Also, family behavior outside child care, such as social gatherings where masking is not enforced, also influence COVID-19 cases when children gather and may affect the numbers of closures.

Having the option of childcare centers benefits kids with in-person early education and social interactions with staff, the authors noted. The centers also help parents return to work without interruptions at home.

“Our findings support current national recommendations endorsed by many local and state governments for masking children 2 years and older in childcare programs when community COVID-19 transmission levels are elevated,” the authors wrote.

Schaffner said the results have implications outside of childcare centers and should be included in discussions of masking in schools and in the general public.

All phases of this study were supported by and coauthors report grants from the Andrew & Julie Klingenstein Family Fund, Esther A. & Joseph Klingenstein Fund, Heising-Simons Foundation, W.K. Kellogg Foundation, Foundation for Child Development, Early Educator Investment Collaborative, and Scholastic. The study was partially funded by the Yale Institute for Global Health. Schaffner and Beamer reported no relevant financial relationships.

Study Highlights

  • In this prospective, 1-year, longitudinal study, 6654 childcare professionals at home- and center-based childcare programs in all 50 states completed an electronic survey at baseline (May 22, 2020-June 8, 2020) and follow-up (May 26, 2021-June 23, 2021).
  • Mean age was 46.9 ± 11.3 years; 11.3% were Black, 0.9% American Indian/Alaska Native, 2.4% Asian, 12.9% Hispanic, 2% multiracial, 0.3% Native Hawaiian/Pacific Islander, and 75.4% White.
  • A generalized linear model (log-binomial model) with robust SEs examined associations between childcare program closure from confirmed or suspected COVID-19 in either children or staff during the study and child masking in early adoption (endorsed at baseline) and continued masking (endorsed at baseline and follow-up).
  • The model controlled for other risk mitigation strategies, including social distancing, symptom screening, outside drop-off, and temperature monitoring; and program and community characteristics.
  • Early adoption of child masking was associated with a 13% lower risk for program closure because of a COVID-19 case (aRR = 0.87 [95% CI: 0.77, 0.99]).
  • Continued masking for 1 year was associated with a 14% lower risk (aRR = 0.86 [95% CI: 0.74, 1]).
  • Adult masking alone was not associated with prevention of COVID-19--related childcare closures.
  • The percentage of programs reporting child masking increased from 9% at baseline to 33% during follow-up.
  • The investigators concluded that masking young children is associated with fewer childcare program closures, which has important public health policy implications.
  • The findings support current CDC recommendations, endorsed by many local and state governments, for masking children aged ≥ 2 years in childcare programs when community COVID-19 transmission levels are elevated.
  • Masking children aged ≥ 2 years can be an important component of risk mitigation strategies for younger children in congregate settings when vaccination is not widely available.
  • Open childcare programs facilitate in-person early education, beneficial social interactions among children and staff, and financial stability by allowing parents to return to work without interruptions from quarantined children.
  • Lack of association between adult masking alone and prevention of COVID-19--related childcare closures may be explained by programs that did not endorse strict masking policies being less concerned about COVID-19 in general and therefore less likely to close for COVID-19 exposures or cases.
  • Benefits of masking in preventing COVID-19 spread within K-12 classrooms are well described.
  • Young children can safely wear masks without compromising respiratory function.
  • Studies showed that preschool children using masks plus other risk-mitigation strategies had fewer respiratory viral infections and no reported asthma symptoms, attributed in part to less face touching when wearing masks.
  • Despite concerns regarding potential social and developmental delays when younger children wear a face mask for prolonged periods because of lack of recognition of emotional cues, evidence suggests that school-aged children can identify most emotions in masked faces.
  • Study limitations include potential respondent bias; lack of data regarding childcare program policies about masking or closure criteria; inability to differentiate between closures from within-center transmission and those from imported COVID-19; and inability to control for other preventive measures, such as avoiding travel, used by adults and children who masked.
  • The results may underestimate the value of masking because SARS-CoV-2 strains circulating during the study were likely less contagious than the Delta variant.

Clinical Implications

  • Masking young children is associated with fewer childcare program closures.
  • Open childcare facilities enable in-person education and has important public health policy implications for families relying on childcare to sustain employment.
  • Implications for the Healthcare Team: The findings support current CDC recommendations for masking children aged ≥ 2 years in childcare programs when community COVID-19 transmission levels are elevated, it is crucial for health care team members to understand the new recommendations and develop strategies for better healthcare practices.

 

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