The American Academy of Pediatrics is recommending that all children over age 2 wear masks in school this fall. The internet rejoiced, everyone agreed it was a great plan, scientists and politicians shook hands, and no one had anything to say about it.

Ha. Kidding. I promptly picked up some curly fries and wine when I heard about it and laid face-down on my office floor. Not the most sanitary place to do some deep breathing, but whatever.

I hate to joke about serious things like this, but if I don’t, I may cry. The idea of a uniform and agreed-upon plan for halting the spread of a disease that could prevent the deaths of many seems like a pipe dream at this point.

Let’s walk through this and see if I can help you with your decisions this fall.

What did the American Academy of Pediatrics recommend?

• “Everything possible must be done to keep school in-person.” This is because the rates of academic struggle, obesity, and mental health crisis all rose tremendously this past year. Kids need to be in school. We all agree on that.
• They recommend all eligible kids receive the COVID vaccine (12 and up currently)
• Universal masking for anyone in school over age 2 (all students and all staff)
• Flexibility in policy – COVID is an ever-changing scenario and if something isn’t working well, schools need to recognize it and change it
• Attendance of students should be closely watched, and mental health resources for both students and staff should be available
• There should be ongoing federal, state, and local funding to schools to help them with all this.

Why is the AAP recommending all kids wear masks this Fall?

• The AAP is asking all students to wear masks in order to not only protect those that cannot be vaccinated yet, but also the families of these children, and the community as a whole.
• The AAP advocates for children. ALL children. Not just your kid. The wealthy ones. The poor ones. The sick ones. The healthy ones. The physically and mentally challenged. The kid who is being raised by his elderly grandmother and doesn’t have the means or transportation to get that vaccine yet. The kid who doesn’t have enough food at home but gets 2 good meals at school. The child who doesn’t have access to the fancy laptop or functioning internet. The AAP gives us advice based on what will help our community better support and protect our kids.
• Guess what? Last year, we masked in schools. We washed hands more. We asked sick kids to stay home. And schools were then found to not contribute significantly to the spread of COVID-19. (Click here for more information)
• We also noticed a pleasant, NONEXISTENT flu and RSV season as an added side-bonus.
• What happened this summer? We took our masks off, had playdates, saw friends, had parties. And now have plunged into a winter-sized scourge of viral illness. My office has been booked days in advance. The hospital is full. In July. These school strategies work not only in regards to COVID, but all viral illness– both focused studies and my own practice numbers have proven this.

What is the “Delta variant”?

• The COVID virus is mutating (as we expected), and this is the newest and most common version of it in the U.S. right now
• It is crazy, freaking contagious. More so than the original bad boy.
• Verdict’s out on whether it makes you sicker. I suspect it will put a larger burden on hospitals just given the number of unvaccinated people who may be infected.
• Vaccines seem to be working well against it.
• A recent study from the United Kingdom showed that children and adults under 50 were 2.5 times more likely to become infected with Delta.

Why should my vaccinated kid wear a mask?

• Because keeping track of who is vaccinated and who isn’t is a huge burden on schools. And trust me, they have already suffered enough burden.
• Because many kids cannot have the vaccine yet, or haven’t had access to it.
• Because we don’t yet know how well the vaccines work against the new COVID variants and until we are more comfortable with seeing how effective it will be, this is the most low-risk and safe thing we can do.

Will masking harm my kid? Why are all these people saying these awful things about masks?

• Putting a piece of thin cloth on your child’s face does not harm your child.
• I have written one mask exemption this entire year. One. It was for a child with a very rare lung disease. The child’s lungs are anatomically and physiologically very different than a normal child’s and keeping oxygen levels up even without a mask was a struggle for this kiddo.
• The worst I’ve seen is a mild face rash here and there. Otherwise, don’t believe the hype. Masks are not causing TMJ problems, lost social development, increased CO2 levels, increased illness, etc etc. It’s a lot of weak arguments with no evidence and as a pediatrician who saw and examined thousands of children this past year: the kids are fine.

Does masking protect other people? Or me?

• Both.
• Even if your child is the only child wearing a mask in the class, it will protect him. (Click here for more information)
• This all works better if everyone masks.
• If an unmasked sneeze happens nearby, a mask prevents your child from inhaling AS MUCH virus into his airway – and there is brewing evidence that the MORE virus particles you inhale into your body, the more severe the subsequent illness may be.
• I also think it really keeps kids from touching their face, picking their nose, putting fingers in mouth, etc. Our absolute lack of flu and RSV last winter can attest to this.

What if only some kids are wearing masks? Will my kids get bullied?

• I don’t know. I doubt it. We did a whole year where everyone masked and school-aged and young kids were generally pretty cool and flexible about it. Most don’t seem to care either way. The bullies in this scenario often seem to be the adults.

When are the vaccines for the younger kids going to be ready?

• Pfizer’s clinical trial data for children age 5 to 11 is likely coming in September. If approved, shots for kids this age will be available within 1-2 weeks after that.
• Ages 2 to under 5 coming soon after that, in October.
• 6 months to 2 years soon after that.

What about my child under 2 who can’t wear a mask?

• It’s okay. Send them to daycare. Send them to mother’s day out. Do the swim lesson. Get the speech therapy. You need it to work, thrive, survive. COVID seems to be milder in young kids. And while I can never guarantee anything in life 100%, I think the benefits outweigh the risks for kids in this age group.

What if the daycare doesn’t require their staff to be masked? Vaccinated?

• I’m hopeful that daycare centers will strongly encourage their staffs to vaccinate and mask up, but I know that not all will. I think you should ask the questions and expect answers from childcare centers. You can certainly make that a part of your decision-making process when choosing where to place your child.

Do kids really get severely sick with COVID?

• COVID in children is mostly mild. No one debates that. But kids (especially the older kids) contribute to the spread in the community.
• Let’s not forget the times it’s not mild. I’ve seen kids with post-COVID chronic fatigue, long-term smell and taste change or loss, multisystem inflammatory problems, psychosis, and cardiac issues that have kept them out of sports for the year.
• We are still learning about the long-term consequences of COVID infection. There is thought that up to 30% of people who have had COVID will develop long-term medical problems.
• I talked to one of the Cook Children’s Pediatric ICU doctors the other day, Dr. Linda Thompson. I wanted her input about kids with more severe illness as she has seen much more of it than I. She said she’s seen more severe illness in older children compared to the younger ages. She also mentioned “please let everyone know I vaccinated my 14-year-old as soon as I could.”

What do you recommend, Dr. Diane? What will you be doing with your kids?

My kids (6 and 7 years old) will be going to school in-person this fall. They will be wearing masks regardless of what the other children are doing. They can take them off when outside. We will talk about it a lot before it happens, and expectations will be clear.

We will practice wearing them while we watch our screen time to get used to them again on our faces. We will pick the favorite fabrics. If our community numbers drop and my children are able to safely get vaccinated this winter, I can’t wait to tell them to take ‘em off.

But until enough of us get vaccinated, COVID is not going away. And it will likely surge again this winter.

As long as the numbers keep climbing in the community, we have to protect not only the kids, but all of us. Remember those hospital numbers in January? Remember the goal of not over-straining our medical resources? Remember Uncle Pete who had a heart attack and there wasn’t a single hospital bed available for him last winter?

I’ve said it before and I’ll say it again: we are building this boat as we float in it. We don’t know what the future holds for us and we are making the best decisions we can in a situation that no one has yet conquered. Having patience as we gather the data and learn from our successes and mistakes is the beautiful and necessary process of science.

And while I’m confident that we’ll get through it together, I need your help.

Ruling out COVID-19 for kids with symptoms (some mild, some more severe) has become the biggest reason for kids visiting our office. We’ve already seen kids getting sick as they go back to school and that makes me nervous about what the upcoming flu season is going to look like.

Because the symptoms of flu overlap with COVID-19 so much, it’s going to be difficult to tell whether flu or COVID-19 is causing your child’s flu-like illness. And, there’s no guarantee that a child can’t get both at the same time.

So with the flu season nearing, you probably have a lot of questions that need to be answered about this possibility:

• Does every child with flu-like illness need to be tested for both?
  • Probably.
• Does getting COVID-19 and the flu at the same time mean your child will be more at risk for severe illness?
  • Probably.
• Will we have enough COVID-19 testing available to continue avoiding unnecessary quarantines?
  • I hope so, but every time we test a child for COVID-19 because they have flu-like illness, we have fewer tests available.

Here are some things you can do to help your child and yourself (and me):

1. Get your child their flu shot. ASAP. The effectiveness of the flu shot does vary from year to year. It’s not perfect. But, it’s the best we have. And even decreasing the amount of flu by 60% this year will change the lives of those children: Avoiding not one but two tests. Avoiding the worrying during the waiting time and wondering if your child has flu, COVID-19 or something else.
    
2. Start practicing hand washing. Children need to be taught to wash their hands adequately and often.
    
3. Wear your mask, even in situations where you think it might not be necessary. It will not only protect against COVID-19, it will protect against the flu as well. We, as a health care provider and a society, cannot afford to have a terrible flu season this year.
    
4. Keep yourself and your child home if you are sick. This is important…every…single…year. But it is especially important this year. Don’t be the family that knocks over the first domino. Even if you aren’t seen by a doctor, waiting a day can be helpful to see if your simple symptoms progress or go away.

Let’s all do our part.

We can do this!

As of Oct. 12, the number of patients who have tested positive reached 1,657, with four of those patients currently in the hospital.

Pediatric cases of COVID-19 have been climbing along with overall cases in Tarrant County. On Sunday, Tarrant County Public Health reported an ‘uptick’ with 794 new cases.

“I’ve been asked frequently about the number of infected children, as well as the number of infected adults locally and throughout the state. We’ve noticed over the last couple of weeks that we’ve had more positive cases here,” said Mary Suzanne Whitworth, M.D., medical director of Infectious Diseases at Cook Children's. “Part of the reason we have more cases here is because we are doing more testing. If you double the amount of testing you do, you would expect to double your number of positive results. If you more than double your number of positive results, that means there’s more disease in the community.”

Cook Children’s COVID-19 positivity rate was near 2.5% in August. Today, our overall positivity rate is 5.3%. Dr. Whitworth says that rate is in line with statewide and national data for children. She says throughout the pandemic, less than 10% of all COVID-19 cases occurred in children under 15 years old.

“It is disturbing that our percent positivity rate is going up, and we also see that in Tarrant County,” she said. “Tarrant County is hovering around 10% positivity rate, while the state has dropped to around 7%.”

There are a number of reasons why this may be occurring, including people going out more and becoming tired of wearing masks and social distancing. She also says there are some cases at schools, but those haven’t been tremendous numbers.

So what can you do to protect yourself and your family?

• Wash your hands often, for 20 seconds with soap and water, or use hand sanitizer.
• Keep at least six feet away from others.
• Wear a mask.
• When around others, remember being outdoors is safer than indoors.

“As the holidays approach, I have wrestled with how to handle this and I know everyone else is wrestling with it too,” she said. “It’s going to be difficult to not be involved in crowded gatherings, but they’re not going to be very safe this year. Those are some of the things I think we can do.”

She says another important way to protect yourself and your family is to get a flu shot.

“There are decades of safety data with flu shots. They are safe. You can’t get the flu from a flu shot. You might be a little achy afterwards, but that beats having the flu where you might be in bed for a week with high fever and miss work or miss school.”

The Centers for Disease Control and Prevention (CDC) is discouraging trick-or-treating nationwide, calling it a high-risk activity for spreading COVID-19. They’re also dissuading trunk-or-treat events (where treats are distributed from trunks of cars in parking lots), indoor parties and haunted houses.

So why are these Halloween favorites considered high-risk?

“We know outdoor activities are much safer than indoor activities,” said Mary Suzanne Whitworth, M.D., medical director of Infectious Diseases at Cook Children's. “The problem is coming in close contact with people you’re not around regularly, like family members.”

She says masks have been very beneficial in slowing the spread of COVID-19, but warns of a recent rise in cases in Fort Worth and surrounding areas.

“Tarrant County has had an increase in COVID-19 cases over the last couple of weeks, and our positivity rate is hanging around 10% or 11%, which is pretty high,” she said. “The State of Texas is several percentage points below that right now. So now is not a good time to increase face-to-face contact locally.”

As of Oct. 5, 672 people had died of COVID-19 in Tarrant County, and nearly 45,000 others have recovered from the virus. With the current uptick, Dr. Whitworth says maintaining six feet of distance from other people is critically important, regardless of the activity.

“When you talk and exhale, you have droplets come out of your mouth and your nose that you don't see. There are a lot of them and they typically fall within three feet, but not always. You may talk louder or you may cough and they might travel farther. This is why the recommendation is to stay six feet apart” Dr. Whitworth explained. “It is less risky if you're outside because most of those droplets are diffused away and diluted outdoors. Of course, it’s even safer if you can wear a mask.”

In case you’re wondering, she isn’t talking about a Halloween mask. Dr. Whitworth says typical Halloween masks have openings for the mouth and nose, which defeats the purpose of stopping the spread of droplets.

But Halloween doesn’t have to lose all of its magic. Rayne Delgado, program coordinator for the Child Life Zone at Cook Children’s, has suggestions on how to make Halloween fun and safe for children this year.

“There are a lot of things families can do instead of trick-or-treating, like scavenger hunts in the house, family movie night and games.” Rayne said. “Pinterest also has a ton of craft ideas that meet all budgets.”

Here are some specific ideas Rayne shared with us:

Sensory fun

• Make Halloween slime and add googly eyes or critters in it
• Create sensory boxes filled with Halloween candy to find
• Build sensory bins with things like fake spider webbing, dyed-spaghetti noodles, soapy water, black beans, crushed graham crackers, un-popped popcorn, dyed rice, and Halloween trinkets (If age-appropriate)

Cooking activities

• Pumpkin face homemade pizza
• Dessert pizza using Halloween candy
• Carmel apples
• Ice cream cone witches hats
• Mummy hot dogs

Games

• Play Halloween-themed bingo
• Create a family mystery game with a play on Clue.
  • Using different rooms in your house, family members are the characters. Swap weapons for costumes.
  • Try to figure out which family member stole what piece of candy from what room, while wearing which costume. (This can also be done virtually with children and their friends. Switch rooms to each other’s houses.)
• Create an escape room in the house.
  • Start with one envelope that needs to be solved. That leads to another with another puzzle and so on until you find the bucket of trinkets/candy.
• Have a costume contest
  • Find things in the house to play dress up with. Who can be the most creative or silliest?

(We have provided templates in the 'Downloads' section of this article.)

Now that schools have opened, who needs COVID-19 testing?

Rapid testing for COVID-19 can be helpful to promote isolation for positive cases, and to prevent prolonged unnecessary isolation for those children exposed to COVID-19 or with questionable symptoms. The symptoms that most likely warrant testing are combinations of the following: fever and headache, vomiting, diarrhea, congestion, loss of taste or smell, cough, muscle soreness, extreme fatigue and shortness of breath. Children with diabetes may see unexplained difficulties with sugar control. Any combination of these symptoms should be taken more seriously if there has been a known contact with a COVID-19 case.

Does a child who has had COVID-19 need a negative test to return to school?

While we have seen some schools and athletic programs requiring a negative test in order to return, this is based on outdated guidance. Testing may remain positive for weeks after symptoms have passed but does not mean that the child remains contagious. The current guidance is that students may return when their symptoms have resolved for 24 hours AND they are 10 days since the start of symptoms. In practicalities, most of these students will be waiting until the 10 days pass. If a child was hospitalized, it is recommend that they wait 20 days from the start of symptoms.

If a child is exposed to COVID-19, can we end their quarantine early with a negative test?

Testing is reasonable if symptoms develop to make a diagnosis, but quarantine should continue for 14 days from the end of the last contact. A negative test should not provide false reassurance as symptoms could continue to develop throughout the 14 day period despite a negative test.

Many parents are concerned about whether their child is at more risk for COVID-19. Which patients are at risk for more severe disease?

Risk factors for severe disease at any age include: cancer; COPD; immunosuppressed state due to organ transplant; obesity (BMI >30); serious heart disease such as heart failure, coronary artery disease, and cardiomyopathies; sickle cell disease; and type II diabetes.

Individuals with the following conditions MAY be at increased risk for severe diseases: asthma; stroke; cystic fibrosis; hypertension; immunocompromised state due blood or bone marrow transplant, steroids, or immunosuppressing medications; neurologic conditions; HIV; liver disease; pregnancy; pulmonary fibrosis; smoking; thalassemia; and type I diabetes.

Children who are medically complex, who have serious genetic, neurologic, metabolic disorders, or congenital heart disease might be at increased risk for severe illness from COVID-19, as well as children with obesity, diabetes, asthma and chronic lung disease, or immunosuppression.

What do you do when a child has a family member who is at risk for severe disease? Does the child’s age matter?

In this situation, distance learning might remain the best option for this family. Because the disease can be contracted at any age, this should not factor into the decision. While child to adult spread may not happen as easily as adult to child, there are studies that show it does occur.

Do children who are planning to do virtual learning need to have their vaccines updated?

According to the Texas Department of State Health Services (TDSHS), vaccine rules are still in effect regardless of whether a student is participating in on-campus or virtual learning.

Read more about Cook Children's recommendations for safely returning to school on our website.

*This post includes information provided by Marc Mazade, M.D., medical director of Infection Control and Prevention at Cook Children’s and Justin Smith, M.D., pediatrician at Cook Children’s Pediatric Trophy Club.