As authorities in many countries make plans for children to return to school by the end of 2021 despite the ongoing COVID-19 pandemic, the debate over whether children can benefit from mask mandate in schools receives more attention than ever. Some even voice against universal masking. In this article, we will discuss the appropriate age for children to begin wearing a mask, its major benefits, and the epidemiological evidence for it.
At what age should children begin masking?
Based on safety, overall public health considerations, and a child’s capacity to use a mask appropriately with minimal assistance, the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) both advise that children aged five and under should not be required to wear a mask. Children aged 6 to 11 can wear a mask if necessary, but only if there are adequate adult supervision and instructions on how to put on, take off, and safely wear a mask. Children aged 12 and above should wear a mask under the same conditions as adults as required by local authority, in particular where the practice of social distancing is difficult to follow.
Nevertheless, different countries have different requirements for children. For example, the Centers for Disease Control and Prevention of the United States (CDC) and American Academy of Pediatrics (AAP) advise that children under the age of two should not wear a mask. All other individuals who are not fully vaccinated should wear a mask indoors and if close contact is unavoidable, outdoors too. In the UK, the Public Health England (PHE) does not recommend face coverings or masks for children under the age of three as they may lead to choking and suffocation.
In Taiwan, the Central Epidemic Command Center (CECC) advises that adults who are in close proximity to infants under one year old should take the initiative to keep at least 1.5 meters between them in indoor public areas in light of the fact that they cannot wear a mask.
In other words, it is better to consult local authorities on recommended practices and abide by their requirements. If it is required for children under the age of five to wear a mask, the WHO advises that a parent or guardian should be within direct line of sight to supervise its safe usage.
3 benefits of children wearing a mask
Studies have shown that there are many benefits for children to wear a mask in school. Below are some of the major benefits.
1. Reduce the chance of getting respiratory infections
The coronavirus infection is spread primarily by inhaling respiratory droplets produced by infected people when they cough, sneeze, sing, talk, or breathe. Most of these droplets are less than 10 micrometers (μm) and are often referred to as “aerosols”. Surgical masks, if worn properly, can effectively block respiratory droplets, splashes, sprays, or splatter that may contain viruses and bacteria. A cloth mask can also offer some protection to the wearer, but the level of protection depends on the fabrics used, the number of layers of fabric and mask size, etc.
In addition to other public health measures such as vaccination, social distancing and improving ventilation in indoor areas, wearing a mask is still a good idea because it reduces the chance of children getting respiratory infections by blocking the inhalation of respiratory droplets (filtration for wearer protection). In general, masks are especially useful in crowded indoor public places where it is difficult to keep a safe social distance and where there is a mixture of vaccinated and unvaccinated individuals.
2. Prevent the spread of COVID-19 to family members
Kids masks can block the release of exhaled respiratory droplets, which carry viruses and bacteria, into the surrounding environment (source control). Therefore, both children and adults are encouraged to wear a mask even though they may not feel sick. This is significant because several studies have found that people infected with COVID-19 who never develop symptoms (asymptomatic) and those who are not yet showing symptoms (pre-symptomatic) can still spread the virus to other people. It is estimated that asymptomatic or pre-symptomatic individuals who are unaware of their infectiousness account for more than half of all transmissions.
If children wear a mask in school, not only can they protect themselves, but they can also prevent the spread of COVID-19 to other family members lest they should become infected but do not show any symptoms. If more people are willing to use masks correctly and consistently, the whole community will definitely benefit from the more effective control of the transmission of viruses.
3. Protect the unvaccinated
Not everyone is suitable for COVID-19 vaccination. According to the WHO, COVID-19 vaccines are safe for most people aged 18 and above, including those with pre-existing conditions of any kind, such as auto-immune disorders. In particular, the WHO’s Strategic Advisory Group of Experts (SAGE) has concluded that the Pfizer-BioNTech vaccine is suitable for use by people aged 12 and above.
In the US, the CDC recommends COVID-19 vaccination to all people aged 12 and above except those who have severe or immediate allergic reactions of any severity after a previous dose or a known and diagnosed allergy to a component of the vaccine.
It is worth noting that although most children who are infected with COVID-19 experience milder symptoms than adults, it is still possible for them to develop serious complications and become very ill. As there is currently no FDA-approved or FDA-authorized COVID-19 vaccine for children under 12 years old, it is crucial that parents and guardians of children under the age of 12 consider letting their children wear a mask in school to protect themselves and others from COVID-19.
Who should not wear a mask?
According to the WHO, children of any age with developmental disorders, disabilities, or other specific health problems should not be ordered to wear a mask. It is necessary to assess their individual situation on a case-by-case basis. Children who have severe cognitive or respiratory impairments with difficulties tolerating a mask should not be required to wear a mask.
The WHO also suggested that children should not wear a mask when playing sports or doing physical activities such as running or jumping for fear that their breathing will be compromised. Other public health measures from maintaining social distance (at least 1 meter), limiting the number of children playing together, to providing access to hand hygiene facilities and encouraging their use should be implemented to prevent the transmission of disease.
In the US, the CDC issued the below guidance on those who are exempt from the requirement to wear a mask:
- a child under the age of 2;
- a person (of any age) with a disability who cannot wear a mask, or cannot safely wear a mask, for reasons related to the disability (for example, people who are hypersensitive to materials used in masks, have difficulty understanding why wearing a mask can protect them, or who have problems controlling their behavior); and
- a person for whom wearing a mask would create a risk to workplace health, safety, or job duty as determined by the relevant workplace safety guidelines or federal regulations.
In order to determine whether a child or a person with certain disabilities should wear a mask, it is necessary to assess their ability to:
- use a mask correctly;
- avoid frequent touching of the mask and their face;
- limit sucking, drooling, or having excess saliva on the mask;
- remove the mask without assistance.
Epidemiological evidence – benefits of wearing masks
Many studies from different parts of the world have confirmed the benefit of universal masking in community-level analyses since the outbreak of the pandemic. It has been demonstrated again and again that following directives from organizational and political leadership for universal masking can significantly reduce the number of new infections and mortality. Different studies also showed reductions in hospitalization growth rates following the implementation of a mask mandate. Other benefits of universal masking revealed from epidemiological evidence include preventing the need for lockdowns, reducing associated economic losses, and most important of all, increasing the likelihood of stopping community transmission. More information and details of the epidemiological evidence for the benefits of wearing masks can be found at the CDC website.
Checklist for parents, caregivers, and community members
- What types of masks should children wear?
- A medical mask is recommended for those with a high risk of getting seriously ill from COVID-19 or who have COVID-19 symptoms.
- Children who are in general good health can wear a non-medical or fabric mask. Remember to wash and completely dry cloth face masks after use.
- Proper mask size
- Ensure the mask is the correct size which can sufficiently cover the nose, mouth and chin of the child.
- The mask should fit snugly along the sides of the face without any gaps.
- Confirm that the mask has no choking or strangulation hazards for young children.
- Children should be taught how to wear a mask properly. They should:
- clean hands for at least 20 seconds if using an alcohol-based hand rub, or at least 40 seconds if using soap and water, before putting on a mask;
- not touch the front of the mask and not pull it under the chin or into their mouth;
- store the mask in a bag or container; and
- not share the mask with others.
- For children with COVID-19 symptoms:
- they should wear a medical mask for as long as they can tolerate it;
- they should be isolated, and medical advice should be sought as soon as they start feeling unwell, no matter how mild the symptoms are; and
- family members or caregivers who come within one meter of the unwell child at home should also wear a mask.
Schools should provide masks to students who need them, including on buses and vans (some children may forget to bring their mask or their families may be unable to afford it).
As mentioned above, there have been several epidemiological studies which support the benefits of universal masking in the fight against COVID-19. In discussing the benefits of children wearing masks in school, it is important for parents and guardians to understand that even though most children who are infected with COVID-19 experience milder symptoms than adults, it is still possible for them to develop serious long-term complications. Moreover, it should be remembered that an infected person begins spreading the virus to others before symptoms appear.
Research supports that mask wearing has no significant adverse health effects for wearers. The benefits of universal masking are derived from the combination of source control and filtration for wearer protection. The relationship between these two basic mask functions is likely complementary and possibly synergistic; thus, individual benefits may increase with increasing community mask use.
Currently there is no FDA-approved or FDA-authorized COVID-19 vaccine for children under 12 years old, which may account for the fact that there are more children hospitalized than ever as the highly contagious Delta variant is on a rampage. It is crucial to take multiple preventive measures, including universal masking in schools, to reduce transmission and avoid severe outcomes in children.