Back-to-School Guidance: A Quick Summary

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As the country faces the prospect of schools reopening, all of us who provide care for children are undoubtedly inundated with questions from family members, friends, and the families of patients. I would like to provide you with a quick tour of current guidance and point out some good resources.

If you have time to read only one article on this topic, I would suggest a summary of the American Academy of Pediatrics (AAP) guidance for school reopening , published in August's issue of JAMA Pediatrics. It is a good review of the much more dense full text of the AAP guidance. The AAP strongly endorses schools reopening when community levels of COVID-19 activity prove safe to do so.

Here's my take on the most important points made in the AAP guidance:

Training. AAP emphasizes the need to train school staff and parents on how to screen for symptoms of COVID-19, ideally daily. Schools should consider working with parents to have parents do daily assessments prior to the child's arrival at school. Training students on proper hand hygiene, proper fit and wearing of masks, and even coughing and sneezing "etiquette" should become part of the curriculum.

Face coverings. AAP recommends universal cloth face coverings for all children 2 years of age and above, to be worn all day at school and not just when in public areas. Exceptions can be made for children who have conditions that would make mask wearing difficult, such as those with technology dependence or respiratory conditions for which masks may exacerbate breathing difficulties. The guidelines note that although surgical masks may be more effective than cloth facemasks, cloth facemasks are assumed to be more widely available and have the benefit of being washable and reusable.

Personal protective equipment (PPE). All school personnel, notably nurses, should have access to PPE.

Building changes. The guideline suggests limiting points of entry and changing arrival and dismissal times for groups of students to limit the typical logjams. Other suggestions:

One-way traffic in hallways
Lunch served in classrooms
More frequent cleaning of outdoor play equipment
Physically distancing desks (6 feet is ideal, but 3 feet may be just as effective if face coverings and partitions are utilized)
Teachers rather than students change class if needed
Keep students in small cohorts with a limited number of teachers, which makes contact tracing and possible quarantine easier and allows for potential use of pooled testing
Discontinue use of nebulizer treatments, instead using HFAs and spacers

Age Matters

There are some notable differences to the AAP's guidance based on the age of the children involved.

Preschool. Not only would distancing be very difficult to implement in these youngest students, but it is not clear that it would be needed. In many countries and even in some states, preschools have reopened without large spikes of infection. That said, working on all of the other mitigation approaches if physical distancing is not possible may be even more important. Even young children can effectively wear masks throughout the day. Working with the children prior to school starting, even practicing wearing face coverings for weeks at home before going to school, can help.

Elementary school. All of the recommended mitigation efforts should be used. Cohorting small groups of students with the same teachers throughout the day may be easier than with secondary school students but probably would still be a challenge.

Middle and high school. Physical distancing appears to provide the most benefit out of all of the mitigation strategies. With older students, schools can consider staggering block schedules and school start and end times. Given that a single teacher does not typically teach all subjects, team-based approaches which expose students to a limited number of teachers, ideally with teachers (instead of students) changing classrooms, may be the best approach. Lockers are discouraged, primarily because locker use leads to congregation of students and presents yet another "high touch" surface that would require at least daily cleaning.

Resources

A few key resources for clinicians, families, and school systems:

Reopening K-12 Schools During the COVID-19 Pandemic. A National Academies of Science report provides additional guidance that is critical to any school system trying to implement a multilevel program to pursue reopening of schools. Some notable guidance in this document:

Suggested members of a school district COVID-19 task force which should be tasked with decision-making responsibilities
Strategies to reduce transmission with discussion of cleaning protocols, ventilation standards, bus transportation, use of face shields vs face coverings
Discussion of creating a culture of health
Procedures when someone tests positive

Healthychildren.org. Includes a page on return to school during COVID-19 written for a lay audience. It could be utilized as a handout in the office.

William T. Basco, Jr, MD, MS, is a professor of pediatrics at the Medical University of South Carolina and director of the Division of General Pediatrics. He is an active health services researcher and has published more than 60 manuscripts in the peer-reviewed literature.

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