New Delhi: Anyone with a young ward knows how difficult it is to make children mask-compliant. As schools work towards reopening, several questions — such as how long to mask a child and at which point can they be allowed to remove it — have become moot points. Guidance on the issue varies across the world, as does paediatricians’ take on it vis-à-vis what governments advise.
In India, the government has been following the World Health Organization (WHO), which does not recommend masking children who are aged five years or less. But doctors claim that children as young as three years “adjust well” to masks and should be encouraged to use them given the potential risks of contraction and passing it on.
Earlier this month, in a provocatively titled article in The Atlantic, haematologist Vinay Prasad, an associate professor of epidemiology and biostatistics at the University of California San Francisco, argued that it is possible the downsides of masking children far outweigh the potential risks they face when exposed without a face covering.
“The issue here is what is the objective of masking children, in which settings and at what age? said Dr K.S. Reddy, president of the Public Health Foundation of India and adjunct professor of Epidemiology at Harvard.
“Children are likely to be unmasked in several settings at home, or even outside home. They could be unmasked and meet people so the likelihood of infection is still there. That is the issue that comes up — is it possible to completely seal off the risk of infection to others?”
He said masking children aged six and above is “reasonable”.
“They should be masked in school transport and in classrooms but not when they are outdoors. There should be as much ventilation as possible in classrooms. There is also a difference in the percentage of adults vaccinated. When 70 per cent of adults are vaccinated, for example, even when children transmit the virus, the risks of severe illness are much less,” he added.
When cases in the community are reducing, then masking requirements too can be more relaxed, he noted.
However, Dr Reddy’s views are divergent from the government’s recommendation of masking children who are aged five years and above. According to the health ministry: “Masks are not recommended for children aged 5 years and under. Children aged 6-11 years may wear a mask depending on the ability of child to use a mask safely and appropriately under direct supervision of parents/guardians. Children aged 12 years and over should wear a mask under the same conditions as adults. Ensure hands are kept clean with soap and water, or an alcohol-based hand rub, while handling masks.”
Some paediatricians feel that starting masking protocol for five-year-olds is too late given the high viral load children often carry and the circulating Delta variant of the SARS-CoV-2 virus that is more infectious than the wild variant.
“Children carry the same viral load as others… Children transmit the infection as much as adults and currently all children in the country are unvaccinated. Though in children without comorbidities, they have a fairly good protection from the innate immune system of the body (though Delta can override that too), they are reservoirs of infection,” Dr Sanjeev Bagai, chairman, Nephron Clinics, told ThePrint.
“They can transmit the virus to parents and grandparents. We have seen children beyond three years get accustomed to vaccines fairly well, apart from the time that they are outdoors or in case of older kids if they are playing professionally. I would say masking children aged three and above is critical in classroom settings. Countries like Israel, some states in the US had to close schools when initially masks were not mandated,” he said, pointing out the immediate need to make N95 masks in paediatric sizes available in the country.
Differing advice on masking kids
There are many different takes on masking children even though the WHO has been fairly consistent in its stance that children younger than five years should be spared. The US Centers for Disease Control (CDC) last month cited the delta variant to push for masking of infants.
“Due to the circulating and highly contagious Delta variant, CDC recommends universal indoor masking by all students (age 2 and older), staff, teachers, and visitors to K-12 schools, regardless of vaccination status,” it said.
The WHO, though, does not push for mandatory masking even in the 6-11 years age group. It says that masking in these kids should be based on factors such as the level of infection in the community, whether the child is capable of adhering to mask protocol and hygiene, if there is adequate adult supervision when wearing or taking off a mask and also the potential impact on learning and psychosocial behaviour. The last was the primary argument in Dr Vinay Prasad’s The Atlantic article.
Public Health England, the UK’s health agency, also does not recommend face coverings for children under the age of 3 “for health and safety reasons”. It also advises a more relaxed masking protocol for children aged less than 11 years.
The Danish Health Authority is even more lenient in its exemption of children wearing masks. “If you are the parent of a child under the age of 12 who cannot wear a face mask, you can instead help your child to have clean hands, and you can keep an eye on whether your child is showing symptoms of COVID-19,” the advisory says.
(Edited by Manasa Mohan)
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