Fort Worth, Texas,
10:40 AM

Cook Children’s Physicians Create Guide to Help Kids Safely Return to School amid COVID-19 Pandemic

As Texas enters Phase 3 of Governor Gregg Abbott’s plans reopen the state amid the COVID-19 pandemic, bars, restaurants, amusement parks and sports venues are working to welcome back patrons.

But for many parents, their biggest concern remains what to do during the upcoming school year.

Medical Director of Infection Prevention at Cook Children’s Marc Mazade, M.D, hears questions about how to reopen school again on a daily basis from his patient families as well as his own colleagues.

“Everyone kept asking me, ‘Are kids even going back to school?’ I don’t really know what the plan is. I certainly hope schools reopen in the fall, but we have some work to do,” Dr. Mazade said.

Seeing a need for more guidance, Dr. Mazade worked with more than 50 Cook Children’s physicians to create “Recommendations for the Practical, Fair and Safe Reopening of Public Schools K-12 in the State of Texas.”

The doctors involved work in a variety of primary care offices as well as specialty clinics including Infectious Diseases, Emergency Services, Cardiology, ENT, Neurosciences and more. Dr. Mazade expects this to be a long-term plan, with elements in it that allow for looser restrictions based on current Centers for Disease Control and Prevention (CDC) guidelines for community transmission. He sent these recommendations to the governor and hopes to provide it to schools for the upcoming year.

Dr. Mazade admits to being cautious as kids return to the classroom, but he also believes a common-sense, careful approach will allow children the best opportunity to remain safe.

Students from kindergartners to high school seniors tend to tolerate infection better than adults, especially elderly people. Cook Children’s prescreening of asymptomatic children preparing for a medical procedure identified around 1% of children of all ages shedding the virus locally at the time of this writing.

“In order to put children safely to sleep, we have been testing children who are preparing for surgery for COVID-19 infection," Dr. Mazade said. "As feared, some children who have no symptoms are testing positive for COVID-19. That shows us that children with no symptoms have COVID-19 in our community and infection can spread unknowingly from person to person. We are urging everyone to continue to take precautions to keep everyone safe.”

The physicians worked on the document with the health and safety of students, teachers and their families at the top of mind, but they also thought about a common-sense approach to help bring a return of normalcy to kids’ lives.

“We want children to wear masks, but we also understand that’s going to be difficult for little kids,” Dr. Mazade said. “They may not understand why they are wearing masks, and it may cause problems for them emotionally. In those cases, we are asking for teachers and other adults around these children to take the proper precaution to protect younger children.”

It’s important to everyone involved in creating this document that kids are able to be kids. For instance, under the guidelines, athletes will return to the playing field, but that may mean playing in front of only family where everyone can be properly spaced out for safety.

“As we begin to look at these issues that students may face, we begin to focus on more than the spread of the virus,” Dr. Mazade said. “One of the concerns that came up was making sure we were screening kids for new problems such as starvation and hunger. We don’t know who all are dealing with these issues right now. The kid next door may not get enough to eat any longer. We want to think about screening for depression, too. We added those things to the document because it’s important to be proactive because the stresses are new, different, and so widespread.”

To view the entire document, including recommendations for school nurses, click here. Some of the highlights include:

Health education: Ample opportunities for hand-washing or use of alcohol-based hand rubs should exist. Teach and remind students to use alcohol-based hand rubs after contacting high-touch surfaces such as door knobs, computers, and devices. Teach students to cough into their elbow rather than their hands. Students should be instructed to try to avoid touching their faces.

Face coverings: In communities where COVID-19 transmission is sustained and in situations where social distancing cannot be maintained, all students, visitors, and school employees should wear face coverings on campus and while riding school busses. The contribution of kindergarten and early elementary students to the transmission of COVID-19 has not been well-established. Because expectations for compliance with face cover wearing is understandably low, and language development is crucially important in early elementary students; the wearing of face coverings should be limited to walking in lines in halls and bus riding for younger students. Exemptions for students with developmental delays, autism, and special needs should be examined on an individual basis.

Sports and sporting events:

  • Cheer squads should designate a single caller with a microphone when practicing and performing.
  • All athletes should practice hand hygiene when situations allow.
  • Signage should be posted, and students frequently reminded to use sanitary wipes to clean exercise and weight equipment before moving to another station during strength and conditioning training.
  • All dancers should practice social distancing when performing wherever they are. Barres should be cleansed with sanitary wipes after dance classes.
  • Color guards should comply with these recommendations for their practices and regarding shared implements.
  • Ticket sales for sporting events and performances should be limited to immediate family members of participants.
  • Social distancing of spectators should be encouraged.
  • Sideline staff should be limited to essential personnel.
  • Concessions should be easy to distribute quickly so that concession lines are kept to a minimum.


  • In communities where transmission of COVID-19 is sustained, choir rehearsals should not resume because high rates of transmission have been documented between grouped singers.
  • Indoor wind and brass instrument rehearsals should not resume until more information is available about transmission during the playing of wind and brass instruments.
  • Outdoor wind and brass instrument rehearsals should comply with social distancing recommendations for bands.
  • Band choreography, drumline, and color guard spacing should take into consideration social distancing recommendations. Students participating in these activities should wear face coverings when unable to maintain social distance and when not performing.

Classroom arrangement, use of large spaces, and assemblies:

  • Classrooms should be arranged to maximize social distancing.
  • Large spaces, where social distancing can be practiced, should be used for meetings and proctored testing. Microphones should be utilized during question and answer sessions.
  • All assembly content should be broadcast to homerooms.

Distance learning:

  • On-line school opportunities for immunosuppressed students to learn and immunosuppressed faculty to teach should be increased.
  • On-line accommodations should be examined for students who are quarantined. Preparations should be made for facility closure and an abrupt return to distance learning.
  • Options should be assured for on-campus or alternative site video education for students in home situations that cannot support distance learning. Special education teachers should be proactively engaged to determine how best to include students with special needs in distance learning activities.

Play and social times: It is important that students play for their physical, social, and psychological development. Wash toys frequently. Wipe down handles on play equipment, swings, and balls with sanitary wipes frequently.

Hunger: Lack of access to food continues to be a major issue during the COVID-19 pandemic. Parents who have never faced the need for assistance are still learning how to navigate through unemployment and mounting debt. Educate teachers and parents regarding signs that students may be starving. A student who is starving may ask about food frequently, hoard food and snacks to eat later or share with siblings, be inattentive or hyperactive, and have emotional swings. Some may have lost the lustrous appearance and may appear thin. Schools should provide lists of resources for families in need.

Emotional and mental health: Students are dealing with extremes of anxiety, frustration, isolation, and uncertainty during the COVID-19 pandemic. Many students have had obstacles that prevent social and physical outlets to diffuse these. Some are grieving the loss of family, friends, and an accustomed way of life. Students may act out, withdraw, show diminishing school performance, have uncharacteristic emotional displays of anger and frustration, or try to self-medicate when experiencing depression and anxiety. Increase staffing to provide emotional and mental health support to students. Screen frequently and proactively for signs of depression and suicidal ideation.

Child maltreatment: During these extremely difficult times of isolation, financial strain, insufficient resources, and parental exhaustion; child maltreatment has reached epidemic proportions. Report any concerns for child maltreatment to appropriate authorities and immediately refer students for evaluation and treatment.

Get to know Marc Mazade, M.D.

I went into infectious diseases because my infectious diseases professors were among the most passionate doctors and teachers who invested in medical students and residents.

When I got into infectious diseases fellowship and received that one-on-one training on a daily basis, my career started blossoming. Everything started coming together. My professors challenged me to keep reading, thinking, and researching, while instilling in me the quiet patience that's required to keep digging via a friendly conversation with kids and their families to uncover a potential diagnosis that might explain an illness.

Kids are fun to treat, because they aren't weighed down by a life of poor health decisions that compromise their chances of getting better. It makes me feel great to see kids get well and back to living the lives they love - playing with toys, going to school, drawing and painting, or participating in dance, sports, band, choir, youth group, or just spending enriching time with their families and friends.

I like mentoring upper level medical students and helping them develop their knowledge of infections that are common in children. They often remember things that I've forgotten. When I'm not at Cook Children's, I love working on my tennis serve and backhand, fishing the abundant lakes, streams and bays of the region, and turning the pages of a well written medical mystery novel.




Comments 1 - 5 (5)
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Debbie McNary
Thank you for this information! As an elementary school teacher, it is helpful for me to link arms with Cooks in knowing how we can work together to keep our kids and their families safe.
Karla D
Thank you so much for publishing this!
Carol Barrientos
great information that will help me in preparing for the new school year in my school and classroom. Great information on what to watch out for with my school parents and families.
Terri Andrews
Thank you!
Maritza Caceres
String orchestra should not be a problem as the kids be seated at the right social distancing and wear masks.
Choir could return to the classroom as teachers can, meanwhile, teach all the music theory that is the fundamental for any musician/singers. Weary masks all the time should be no problem in choirs.