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Kids, Classrooms and COVID-19

Zachary Hoy, MD

Pediatricians Weigh in on Risks, Benefits of Heading Back to School

As schools reopen across the U.S., pediatricians are scrambling to help parents navigate growing concerns in children's health. But a nationwide decline in routine vaccinations and well-child check-ups - coupled with missed opportunities to aid at-risk kids through spring and summer school programs - have physicians concerned about more than just academics.

A New Normal

Zachary Hoy, MD, pediatric infectious disease specialist at The Children's Hospital at TriStar Centennial Medical Center and Nashville Pediatric Infectious Disease, said most practices have returned to normal hours, with a handful of new protocols in place. "In March, our clinics switched to telehealth-based appointments as we worked to figure out how to keep staff and patients safe," said Hoy. "By now, I feel like most clinics have good policies in place for sick or back-to-school visits, so we're encouraging parents to schedule those check-ups and vaccinations they might have been putting off."

Meg Rush, MD, MMHC

Meg Rush, MD, MMHC, president of Monroe Carell Jr. Children's Hospital at Vanderbilt, said routine checkups serve multiple purposes and shouldn't be ignored. "We know that well-checks, procedures and health visits are essential to the overall well-being of children and adolescents," she said. "During scheduled visits, doctors evaluate a child's growth and development, assess health issues and manage ongoing healthcare needs. These visits are just as important amid a pandemic as they were before COVID-19 arrived in our community, and so we urge parents not to delay routine care that is vital to their child's ability to thrive."

Addressing Immunizations

From April 2019 to April 2020, Tennessee providers gave 43 percent fewer immunizations - an alarming stat for schools and physicians, alike. Amid a growing trend toward anti-vaccination sentiments, Hoy said it's essential to continue educating parents. "There are several things that we can't protect against, so it's important to get school-related vaccines and physicals," he noted of risks that can be mitigated.

Anna Morad, MD

Anna Morad, MD, pediatrician at Monroe Carell Jr. Children's Hospital at Vanderbilt and president of the Tennessee Chapter of the American Academy of Pediatrics, blames misinformation for confusion about vaccinations. "It really concerns me when I see families declining all vaccinations," she said. "Do they really know what each do? Parents need to think about each one separately and to have an accurate source of information."

That's because fewer vaccinations mean a loss of herd immunity to diseases like measles and pertussis. "It's one of the most important things we do for children's health, and no parent wants their child to get sick," said Morad, recognizing that families who aren't vaccinating feel like they're acting in their child's best interest. "Do they fully understand the risk of contracting one of these illnesses? Until it happens in your child, it's hard to comprehend. Pediatricians should have a good conversation about vaccinations, and parents should be able to ask questions without feeling judged or attacked."

Keeping Patients Safe

Clinics and hospitals have taken lengthy measures to keep patients safe. Hoy's patients - often high-risk - have swapped the waiting room for the car, are provided masks at the door and are encouraged to wash hands often. Emergency rooms, still avoided by some fearful families, have often been redesigned to keep patients safe. Preventative measures at The Children's Hospital at TriStar Centennial include two separate waiting rooms in the Pediatric ER - one for children with symptoms of COVID-19 and the other for those with non-respiratory emergency concerns. Patients and visitors are screened with a temperature check upon entry, while pediatric patients are allowed one visitor at a time in the Emergency Room and hospital. Universal masking and frequent cleaning of common areas like waiting rooms also have been implemented.

Children's Hospital at Vanderbilt has taken similar measures, said Rush. "We are working to reassure families that we have public health safety measures in place to protect them against COVID-19 as they seek vital care for their children," Rush said. "I know community pediatricians have implemented similar measures at their practices. In our hospital and clinics, we have taken extra steps to ensure safety for children and families, including screenings, requiring that everyone wear masks and providing socially distanced seating areas, to name a few things."

Hoy said most parents understand the new reality, and they're starting to feel more comfortable coming in with new procedures in place. "Schools will be the same way," he said. "This school year will look different, but soon everyone will get used to the new normal."

Back to School

Returning to school has been an emotional topic for parents and school leaders, and Morad stressed the decision is not one-size-fits-all. "We want to be mindful that returning to school is best done in the context of a local environment and family situation," she said. "Circumstances are so different for each family and school."

To that end, the AAP has developed guidelines to help mitigate the disease. "We don't have the ability to eliminate COVID," said Morad. "We want to mitigate the impact of COVID in the safest way possible for children, teachers and staff. But the AAP does believe we need them back to in-person learning when it is safe to do so."

AAP's COVID-19 Guidance for School Re-entry notes, "Policies to mitigate the spread of COVID-19 within schools must be balanced with the known harms to children, adolescents, families, and the community by keeping children at home."

Mitigating Risks

Morad said masking should still be the top priority for children developmentally able to wear one, but she stressed masks are protective, not preventative. According to the AAP, the CDC's social distancing guideline of six feet may be unfeasible in schools, where three feet may "approach the same benefits if students are wearing face coverings and are asymptomatic."

Schools also can open doors and windows to encourage air flow, create plexiglass barriers, split classes into smaller groups, avoid assemblies and encourage frequent hand washing. AAP guidelines also suggest adults and adult staff within school maintain a distance of six feet from other persons as much as possible, particularly around other adult staff. Other strategies to increase adult-to-adult physical distance in time and space should be implemented, such as staggered drop-offs and pickups, preferably outside when weather allows.

It's an undeniable amount of planning for school leaders, but pediatricians agree the payoff will be worth it. A sobering reality of virtual classrooms is the nationwide drop in reported cases of child abuse. In Tennessee, reports were down 27 percent during peak stay-at-home orders - a result of fewer kids being seen by school staff and trusted adults. Meanwhile, free lunch and backpack programs are a lifeline for the one in seven kids in the U.S. affected by food insecurity. To that end, Morad said many pediatricians are now screening for food insecurity and other socio-economic factors. "It's important to screen for social determinants of health, things that will improve health for the entire family and child," Morad said.

Parents also should discuss concerns about academic performance with their pediatrician, who can help advocate for additional school services. Likewise, parents of children with underlying medical conditions should discuss risks vs. benefit of returning to class. Morad encourages pediatricians to grow their support network by connecting to resources in their communities. "We need to be coordinating and working within our existing infrastructure," she said. "Being good stewards and helping to connect people is an important part of being a pediatrician."

And while COVID-19 in some classrooms is ultimately inevitable, Morad said school leaders need to remain flexible. "We anticipate we'll see cases as schools reopen, so we need to figure out how we react to those in a mindful and careful way, understanding that completely going back to virtual may put our most vulnerable children at more of a disadvantage," she said.



The Children's Hospital at TriStar Centennial

Monroe Carell Jr. Children's Hospital at Vanderbilt

Vanderbilt Center for Child Health fParent Survey

AAP Healthy Children

AAP Return to school Guidance


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Anna Morad, COVID in Classrooms, COVID-19, Meg Rush, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville Pediatric Infectious Disease, Pediatrics, Tennessee American Academy of Pediatrics, The Children's Hospital at TriStar Centennial Medical Center, Zachary Hoy
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