June 26, 2020
by Trisha Korioth · Staff Writer

As schools and states develop plans for students to return to school during the COVID-19 pandemic, the AAP has updated interim guidance to reflect the growing understanding of the virus’ impact on children and adolescents. 

COVID-19 Planning Considerations: Guidance for School Re-entry” stresses the fundamental role of schools in providing academic instruction, social and emotional skills, safety, nutrition, physical activity, and mental health therapy. 

Schools are critical to addressing racial and social inequity. School closure and virtual educational modalities have had a differential impact at both the individual and population level for diverse racial, ethnic, and vulnerable groups, according to the guidance. Evidence from spring 2020 school closures points to negative impacts on learning. Children and adolescents also have been placed at higher risk of morbidity and mortality from physical or sexual abuse, substance use, anxiety, depression, and suicidal ideation. 

“The AAP strongly advocates that all policy considerations for the coming school year should start with a goal of having students physically present in school,” according to the guidance. These coordinated interventions intend “to mitigate, not eliminate, risk” of SARS-CoV-2. 

Pediatricians can reference the guidance when answering parents’ questions about cloth face coverings and masks; temperature checks; social distancing in classes, hallways, and on buses; and how to navigate the needs of students with disabilities and those who receive behavioral health and emotional support from schools. 

Ideally, pediatricians will have completed students’ well-child visits and had the opportunity to ensure that school immunization requirements have been maintained. The guidance encourages pediatricians to work with schools and local public health leaders to promote childhood vaccination messaging. Annual influenza vaccination is encouraged for all students and staff members. 

Social distancing, mask use
How to effectively observe social distancing and wear cloth face coverings is addressed in the guidance, which examines factors such as students’ ages, developmental stages and special considerations. 

“Evidence suggests that spacing as close as 3 feet may approach the benefits of 6 feet of space, particularly if students are wearing face coverings and are asymptomatic,” according to the guidance. 

Schools should weigh the pros and cons of enforcing 6 feet of distancing. If it is not feasible without limiting the number of students, other risk-mitigation strategies may be more favorable. 

High- and low-priority strategies are provided for distancing and cloth face coverings by age. High-priority strategies include the following: 

  • For pre-kindergarten students, cohort classes, spend time outdoors, and limit visitors to the building. The impact of physical distancing is small and difficult to implement in this age group.
  • Elementary students should wear face coverings if the risk of touching their mouth or nose is not greater than the benefit of reducing the spread of COVID-19. When possible, spacing desks 3 to 6 feet apart and using cohort classes and outdoor space, is recommended
  •  Physical distancing may have a bigger impact on reducing the risk of COVID-19 among secondary school students. When feasible, use face coverings when closer than 6 feet apart, avoid close proximity (and go outdoors if possible and spread out) during activities like singing and exercising, and consider cohorting classes. 
  • Pediatricians can work with families and schools to identify and develop accommodations for children with unique needs. 

During the school day, students also must navigate physical distancing in enclosed spaces, such as buses, hallways, playgrounds, and cafeterias. Other distancing measures include:

  • Assign seats to bus riders by cohort, use face coverings if distancing is not possible, and minimize the number of riders within reason. Encourage students who have other options to use alternative transportation.
  • Reduce congestion inside the building with one-way hallways (tape arrows on floors), rotate teachers instead of students, stagger class periods, and assign lockers by cohort or eliminate lockers.
  • Group students by cohort for meals. Students could eat in their classroom or use outdoor spaces when possible. The guidance stresses that care should be taken to protect students with food allergies from potential exposure. Decisions about how to serve meals also should take into consideration food security and the possible increase in students eligible for free or reduced meals. Emphasize the importance of physical distancing to adults with staggered drop-offs and pickups, limiting parents from entering the building, installing plexiglass in reception areas, and discouraging shared lounges. 

Testing and temperature checks
It is important to have policies to ensure a rapid response to a student or staff member with fever who is in the school and to ensure that students and staff are appropriately screened if they develop COVID-19 symptoms. However, testing is not feasible prior to the start of school in most locations and is not known to reduce the likelihood of spread in schools.

Temperature screening and checks should be balanced with the practicality of doing such procedures at a large scale. In lieu of screening after school arrival, families should keep children home if their child has a fever of 100.4 degrees Fahrenheit or higher and symptoms of or exposure to someone with COVID-19 virus. Allowing parents to record and report temperature at home can be considered, but the epidemiology of disease in children and possible complications for the family should be considered. 

Advocating for students’ needs 
As students reenter school, pediatricians are encouraged to advocate for the overall health and well-being of children and adolescents in their communities. Pediatricians also can ensure that school policies are flexible and can be adapted based on the level of viral transmission and that schools communicate with public health authorities to meet students’ unique needs.

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