Masks and Why They Work For School

Ever since SARS-CoV-2 came to the United States there has been an ever changing influence on our daily lives.  Our kids have been no exception, having to leave in-person school early.  As parents we attempted to accomplish eLearning at home while holding down a job and keeping the peace in the house.  I think many parents quickly learned just how important our teachers are in the last few months.  

As a pediatrician I have also seen just how important being at school is for my patients.  Not only are we seeing an increase in obesity in those kids who normally would be playing sports, being active in gym class, etc; I have also seen an increase in anxiety, depression, and at least one teenager who attempted suicide due to a sense of feeling lost.  The lack of social interaction, peer involvement, physical activity, food security, and other factors have played a heavy toll on our younger population.  I am not the only one who is seeing this – I have spoken with many pediatricians across the country with the same experience. 

When the American Academy of Pediatrics recently released their recommendation of kids returning to school in-person, it was met with mixed reviews.  Some parents cheered this, excited for the prospect of not having to continue home teaching or online classes.  To be honest, I have met with many parents in the office who have admitted that online learning barely happened at home due to parental job restraints and lack of requirements by school districts to complete assignments.  These kids had a huge jump in screen time, leading even more to inactivity and decreased social involvement and educational development.  

Other parents and community members were surprised at the recommendation.  As we still discuss social distancing and the importance to minimize spread of the virus, people wonder why the rush?  If you follow the news or online pundits, you may have seen this recommendation by the AAP used to push an all-out opening of all schools across the board.  However, if you actually read the full AAP statement it plainly states that each state and school district must take into account the local spread of the virus and its impact on in-person meetings and education.  

One of the biggest disagreements about the return to school scenario has been masks.  Should it be required?  Should it be left up to the parents?  Somehow the wearing of masks has become politicized in our country, and it now seems like a badge of acceptance or resistance of social measures.  The biggest question is WHY we should be wearing masks in public.  If a person is perfectly healthy without preexisting conditions, shouldn’t a mask be optional?  Where is the science behind these recommendations?  

Well, there is in fact science despite what the critics tell you.  Early in the course of COVID-19 infections data was lacking.  That was because there was minimal information on this new virus, such as how it is spread, how quickly it may infect someone, when are people most infectious with it, etc.  That takes a LOT of data collection to understand those specifics.  This is where variations in recommendations occurred almost on a weekly basis.  Some if it is still under study.  For instance, the original SARS-CoV-1 virus (or SARS for those who remember it), was most infectious when people were already showing symptoms for several days.  This helped in identifying individuals who were sick and prevented them from spreading it to others, keeping the virus from expanding globally.  SARS-CoV-2, on the other hand, tends to be most infectious a couple days before showing symptoms to a couple days after.  This window of spread not only allows for presymptomatic spread by individuals but can also allow for spread when the infected individual has only mild symptoms.  Who here has allergies?  Mild congestion, scratchy throat, etc – this could be your allergies acting up OR it could be the only symptoms a person presents with early on with SARS-CoV-2.  This is information that we did NOT know when the virus reached our shores. 

Now the question of masks.  It is correct that recommendations varied greatly early in the course, mostly based off of varying and small data sets.  What we DO know and understand is that masks are not always there to protect the individual; they are there to protect you from unknowingly spreading the virus to others.  If SARS-CoV-2 acted like the first SARS virus, we most likely would not be in the situation we are in now.  However, we are stuck in a scenario where any of us could be spreading the virus unknowingly.  When surgeons wear masks during surgery, it isn’t to keep the physician safe from the unconscious patient on the table.  It is to keep the surgical field sterile in order to prevent infecting the patient.  Surgeons don’t get into surgery feeling sick and thus don the mask; they wear it regardless of how they feel.

Mask material has been a huge debate as well.  The naysayers utilize the size of the virus particle to argue that masking really is of no benefit as it can’t keep the virus from moving through the openings between threads.  The issue with this argument is that one assumes that the virus moves on its own from person to person.  This is not the case.  When discussing the ability of a virus to spread, one must understand how it is done.  We discuss hand washing, preventing the touching of your face, etc, but knowing how it moves through the air is just as important.  You may have heard terms like droplet, aersolization, etc, in regards to this.  The varying terminology here dictates the size of the spreading particle and how far it can move through the air. 

Let’s imagine walking through a doorway.  Your body size is small enough to fit without issue.  But what if your only means of transportation was in your car?  Your legs can’t carry you through the doorway.  You can’t crawl through it.  All you have is this big vehicle of metal to take you from point A to point B.  I am pretty sure your car can’t make it through the same doorway you were walking through a moment ago.    This is the same idea of droplet spread with a viral particle.  The virus itself may be able to fit through the openings of threads in your cloth shield, but the droplets have a much harder time.  

Another common question I am getting from patients and parents is how do we expect kids to keep masks on the entire day?  I had a 14-year-old in the office last week complaining that he feels like he can’t breathe in one.  I asked him how many times he has worn a mask this summer and he stated it had been very little.  In fact, outside of our office I am not sure he has utilized one at all.  He was not used to the feeling of having a piece of cloth around his mouth or the feeling of his breath back on his face.  He was fine during the entire visit.  His oxygen levels didn’t drop.  He laughed like every other kid does when doing an abdominal exam – apparently you are never too old to be ticklish.  He FELT like he couldn’t breathe in the mask, but really what he felt was the unfamiliarity of wearing the mask.  Just like wearing glasses, a hat, or clothing in general – it takes routine and frequency to become comfortable with the sensation of something being on your body.  

With all of this in mind, there really is one deciding factor in all of this.  It is the PARENTS’ opinion of masking that is going to either make this work or cause conflict for the teachers and other staff at schools this coming Fall.  Our kids mimic our fears, joys, and even frustrations.  When we are constantly complaining about the news or the latest email the schools have sent out, our kids pick up on this.  If we are resistant to them wearing masks they will be as well.  Using plain language to discuss masks and why they are important is key to helping kids understand.  Don’t be doom and gloom.  Talk about it just as you would talk about any other topics you want your child to understand.  You can utilize this time to teach your kids the importance of public health and caring for your neighbor.  If you want to complain to your spouse or friends about it, do it out of ear shot of your kids.  We are all entitled to an opinion, but opinions don’t change the science of masking. 

In summary, masking is important in preventing the spread of illness just as much as washing our hands.  Make sure your child knows how to wear the mask appropriately: the mask should cover the mouth and nose.  The mask should fit under the chin.  Be sure to wash your cloth masks regularly to prevent them from collecting bacteria and becoming a vector for illness.  

We are all in this together.  There is no reason the idea of wearing a mask should be a political debate.  We all want to try to get back to normal.  Closing our eyes and running into the street hoping to make it across isn’t the answer.  If you have questions about your child and school or masking in general be sure to contact your primary care provider about it.  

Imperfect Dad, MD

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