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COVID-19 and school return: The need and necessity

Published:August 04, 2020DOI:https://doi.org/10.1016/j.pedn.2020.07.015
      A national discussion is underway concerning the safe return of children to school. Since early 2020, when not only this country but the world came to a halt in response to the declaration on March 11 of the COVID-19 Pandemic by the World Health Organization (WHO), health care professionals, scientists, government and public health officials have worked to ensure the health and safety of the public with attention to the most vulnerable (). Several editorials have been published in this journal addressing the COVID-19 health concerns pertaining to children (
      • Fry-Bowers E.K.
      Children are at risk from COVID-19.
      ;
      • Vessey J.A.
      • Betz C.L.
      Everything old is new again: COVID-19 and public health.
      ). One of those editorials, authored by Dr. Eileen
      • Fry-Bowers E.K.
      Children are at risk from COVID-19.
      , entitled Children are at Risk from COVID-19 was cited at a recent Senate Hearing by Senator Cassidy of Louisiana. The circumstances have since changed and will continue to evolve with ever increasing knowledge and understanding about SARS-CoV-2 virus that causes COVID-19 (). As this Pandemic continues, urgent efforts have been undertaken to treat those critically and seriously ill, prevent the spread of infection and develop a vaccine for population protection (
      • Rajmil L.
      Role of children in the transmission of the COVID-19 pandemic: A rapid scoping review.
      ). It is timely to address this pressing concern for families, children and youth-returning to school safely in the midst of this Pandemic and the roles and responsibilities of pediatric nurses in supporting their school return.
      As evidence accumulates to inform treatment and public health preventive practices, questions arise as to the current and long-term psychosocial concerns and risk factors affecting the health and wellbeing of children that are the indirect yet problematic effects of the COVID-19 Pandemic (
      • Rajmil L.
      Role of children in the transmission of the COVID-19 pandemic: A rapid scoping review.
      ). Child health experts, educators and families themselves, are calling attention to the actual and potential consequences of the necessary preventive practices of social distancing and stay at home directives (;
      • Centers for Disease Control and Prevention
      Health Department-Reported Cases of Multisystem Inflammatory Syndrome in Children (MIS-C) in the United States.
      ;
      • Fitzgerald D.A.
      • Nunn K.
      • Isaacs D.
      Consequences of physical distancing emanating from the COVID-19 pandemic: An Australian perspective.
      ;
      • National Academies of Sciences, Engineering and Medicine
      Schools Should Prioritize Reopening in Fall 2020, Especially for Grades K-5, While Weighing Risks and Benefits Retrieved on July 20, 2020 from.
      ;
      • National Association of Pediatric Nurse Practitioners
      Prioritizing Return to School for Children in COVID-19 Policy Planning Retrieved on July 20, 2020 from.
      ). Pediatric nurses have important roles and responsibilities in providing evidence-based guidance and support to parents, children and youth about preventive practices on the safe and needed return to school. It is understandable that parents, their children and the public are anxious about school return given the unrelenting yet needed focus on containing this Pandemic; however, the attention to the science is needed when providing guidance.
      Data reported worldwide indicate lower rates of infection in children. In Iceland, no children under 10 years of age were reported positive; for those 10 years of age and older, 0.8% were infected (
      • Gudbjartsson D.F.
      • Helgason A.
      • Jonsson H.
      • Magnusson O.T.
      • Melsted P.
      • Norddahl G.L.
      • Saemundsdottir J.
      • Sigurdsson A.
      • Sulem P.
      • Agustsdottir A.B.
      • Eiriksdottir B.
      • Fridriksdottir R.
      • Gardarsdottir E.E.
      • Georgsson G.
      • Gretarsdottir O.S.
      • Gudmundsson K.R.
      • Gunnarsdottir T.R.
      • Gylfason A.
      • Holm H.
      • Jensson B.O.
      • Stefansson K.
      Spread of SARS-CoV-2 in the Icelandic population.
      ). In Italy, children younger than 18 years of age accounted for 1% of the total population infected with COVID-19; none of these children died (
      • Parri N.
      • Lenge M.
      • Buonsenso D.
      • Coronavirus Infection in Pediatric Emergency Departments (CONFIDENCE) Research Group
      Children with Covid-19 in pediatric emergency Departments in Italy.
      ). In the United States, as of August 6, 2020, 380,174 children have been infected representing 9.1%of the COVID-19 population. However of concern, a more recent spike of 179,990 children with COVID-19 was reported from July 9 to August 6 demonstrating the ever-changing nature of this Pandemic. The pediatric COVID-19 deaths reported by states, now ranges from 0% to 0.4%, with nineteen of the states reporting no COVID-19 deaths of children (, ). Currently, the evidence suggests that low levels of transmission are associated with children (
      • Lee B.
      • Raszka Jr., W.V.
      COVID-19 transmission and children: The child is not to blame.
      ;
      • Rajmil L.
      Role of children in the transmission of the COVID-19 pandemic: A rapid scoping review.
      ). The evidence also reveals that contact tracing of children with COVID-19 is associated with household contacts (
      • Kelvin A.A.
      • Halperin S.
      COVID-19 in children: The link in the transmission chain.
      ;
      • Lee B.
      • Raszka Jr., W.V.
      COVID-19 transmission and children: The child is not to blame.
      ;
      • Posfay-Barbe K.M.
      • Wagner N.
      • Gauthey M.
      • Moussaoui D.
      • Loevy N.
      • Diana A.
      • L'Huillier A.G.
      COVID-19 in children and the dynamics of infection in families.
      ). In Ireland, contact tracing of 6 individuals (3 children; 3 adults), reported no confirmed cases of COVID-19 as transmitted to school children involving 924 child contacts and 101 adult contacts (
      • Heavey L.
      • Casey G.
      • Kelly C.
      • Kelly D.
      • McDarby G.
      No evidence of secondary transmission of COVID-19 from children attending school in Ireland, 2020.
      ). It would appear that children of elementary school age are at the lowest risk of infection (
      • Lee B.
      • Raszka Jr., W.V.
      COVID-19 transmission and children: The child is not to blame.
      ).
      Children with COVID-19 infection may be asymptomatic or have mild symptoms (
      • Posfay-Barbe K.M.
      • Wagner N.
      • Gauthey M.
      • Moussaoui D.
      • Loevy N.
      • Diana A.
      • L'Huillier A.G.
      COVID-19 in children and the dynamics of infection in families.
      ;
      • Viner R.M.
      • Russell S.J.
      • Croker H.
      • Packer J.
      • Ward J.
      • Stansfield C.
      • Booy R.
      School closure and management practices during coronavirus outbreaks including COVID-19: A rapid systematic review.
      ). The mild symptoms reported in children have been headaches, nasal discharge, loss of smell and gastrointestinal symptoms (
      • Posfay-Barbe K.M.
      • Wagner N.
      • Gauthey M.
      • Moussaoui D.
      • Loevy N.
      • Diana A.
      • L'Huillier A.G.
      COVID-19 in children and the dynamics of infection in families.
      ). Noteworthy, as with adults, children who have medically complex conditions, those who are obese and with long-term conditions are at higher risk for COVID-19 infection (
      • Wyckoff A.S.
      AAP news: CDC: Obesity among conditions that up risk of severe COVID-19 disease.
      ). Reports of children diagnosed with a Kawasaki-type syndrome, Multisystem Inflammatory Syndrome in Children (MIS-C) due to SARS-CoV-2 is rare (
      • American College of Cardiology
      ACR MIS-C and COVID-19 related Hyperinflammation task Force. Clinical Guidance for Pediatric Patients with Multisystem Inflammatory Syndrome in Children (MIS-C) Associated with SARS-CoV-2 and Hyperinflammation in COVID-19.
      ;
      • Munro A.
      • Faust S.N.
      Children are not COVID-19 super spreaders: Time to go back to school.
      ). According to the Centers for Disease Control and Prevention (CDC) report of August 6, 2020, there were 570 cases and 10 deaths reported (CDC, 2020). Given the aforementioned evidence, experts worldwide and including those in the U.S. are recommending that children go back to school (
      • Munro A.
      • Faust S.N.
      Children are not COVID-19 super spreaders: Time to go back to school.
      ).
      Most recent reports indicate that the pattern of illness in children is similar worldwide, including low and middle income countries (LMIC) (
      • Zar H.J.
      • Dawa J.
      • Fischer G.B.
      • Castro-Rodriguez J.A.
      Challenges of COVID-19 in children in low- and middle-income countries.
      ). However, children in LMIC are thought to be at greater risk given the prevalence of malnutrition, HIV, lower tract respiratory infections and other infectious diseases such as malaria and cholera. As well, LMIC are under resourced in terms of available health services and needed supplies for COVID-19 treatment and preventive measures. Additionally, sanitation and social conditions associated with poverty such as overcrowding, inadequate housing adversely affect children and their families in accessing services and supports during the pandemic. Of major concern in LMIC as well as globally, are the adverse psychosocial effects of social isolation, and lack or limited remote access to educational programs (
      • Lee J.
      Mental health effects of school closures during COVID-19.
      ). Of concern in LMIC is the COVID-19 impact on the provision of essential health services such as maternal-child care (
      • Menendez C.
      • Gonzalez R.
      • Donnay F.
      • Leke R.
      Avoiding indirect effects of COVID-19 on maternal and child health.
      ).
      According to a recent
      • UNESCO
      Education: From disruption to recovery.
      , 143 countries have closed schools affecting more than a billion learners in an effort to contain the global pandemic. Although these efforts have been undertaken to slow the spread of COVID-19, child health experts warn of adverse consequences for their learning, social and emotional well-being (
      • Heavey L.
      • Casey G.
      • Kelly C.
      • Kelly D.
      • McDarby G.
      No evidence of secondary transmission of COVID-19 from children attending school in Ireland, 2020.
      ). Other problems include lack of access to school-based mental health service and access to primary care through a school-based clinic. Additionally, the schools serve as a resource that provides needed child care support enabling parents to work (
      • Rothstein R.
      • Olympia R.P.
      School nurses on the front lines of healthcare: The approach to maintaining student health and wellness during COVID-19 school closures.
      ). Also affected are disruptions to the child's daily routines as the structure of the school day promotes the child's wellbeing (
      • Rothstein R.
      • Olympia R.P.
      School nurses on the front lines of healthcare: The approach to maintaining student health and wellness during COVID-19 school closures.
      ). Needed playful and physical activities as well as organized sports are now curtailed with school closures. Other options for children and youth such as access to child care settings, parks, public pools, and organized sports activities, and summer camps are now restricted (
      • Teo S.
      • Griffiths G.
      Child protection in the time of COVID-19.
      ).
      Additionally, children are exposed to new family stresses and disruptions caused by the pandemic. Families face parental unemployment, uncertain financial situations and worrisome issues pertaining to family incomes (
      • Lee J.
      Mental health effects of school closures during COVID-19.
      ;
      • Viner R.M.
      • Russell S.J.
      • Croker H.
      • Packer J.
      • Ward J.
      • Stansfield C.
      • Booy R.
      School closure and management practices during coronavirus outbreaks including COVID-19: A rapid systematic review.
      ). The consequences of parental unemployment/underemployment have immediate and far reaching effects. For many families, funds for discretionary spending will by necessity need to be reallocated for more basic familial needs for food and shelter and thereby indirectly affecting usual family-and child-centered activities. For some families, housing arrangements may necessitate overcrowding or result in possible homelessness (
      • Fitzgerald D.A.
      • Nunn K.
      • Isaacs D.
      Consequences of physical distancing emanating from the COVID-19 pandemic: An Australian perspective.
      ).
      As experts caution, the acute and long-term mental health effects of the pandemic need to be acknowledged and investigated. That is, children are now experiencing a myriad of social and personal crises during this pandemic-social isolation from friends, disruptions in daily activities, and family hardships that are challenging now and may manifest later as having difficulties with school reintegration, academic performance and emergence of behavioral problems (
      • Wade M.
      • Prime H.
      • Browne D.T.
      Why we need longitudinal mental health research with children and youth during (and after) the COVID-19 pandemic.
      ). Vulnerable children such as those living in poverty, those with learning disabilities and special needs, and living in toxic social situations can be at higher risk for mental health problems (
      • Wade M.
      • Prime H.
      • Browne D.T.
      Why we need longitudinal mental health research with children and youth during (and after) the COVID-19 pandemic.
      ).
      Of particular concern are the consequences for children who live in poverty. These children live in homes that have inadequate resources for virtual learning that will contribute to learning deficits, and thereby falling further behind with expected academic performance for grade level. Children from low-resourced homes are likely to have limited space for doing school work, inadequate temperature controls for heating and cooling and safe outdoor space for exercise (
      • Van Lancker W.
      • Parolin Z.
      COVID-19, school closures, and child poverty: A social crisis in the making.
      ). Furthermore, this group of children are at high risk for food insecurity as they may not have access to school lunches/breakfasts with school closures (
      • Rothstein R.
      • Olympia R.P.
      School nurses on the front lines of healthcare: The approach to maintaining student health and wellness during COVID-19 school closures.
      ;
      • Van Lancker W.
      • Parolin Z.
      COVID-19, school closures, and child poverty: A social crisis in the making.
      ). As has been demonstrated, the “learning gap” between children from families who live in poverty compared to those who do not will likely widen as has been evidenced in previous studies examining school summer vacations (
      • Van Lancker W.
      • Parolin Z.
      COVID-19, school closures, and child poverty: A social crisis in the making.
      ).
      As the national dialogue continues about reopening schools, pediatric nurses have opportunities to listen to the concerns of parents and the public and provide evidence-based guidance on school return whether in hospitals, outpatient clinics or community-based settings where care is provided. These are important times to assist parents with their questions and address their worries and anxieties about their children's return to school. As nursing professionals, offering families with evidence-based guidance and the resources they need to make informed decisions is essential. At this time, school-nurses will have important and pivotal roles in school settings to inform their school-based colleagues, families and students on the evidence and best practices. A number of valuable resources are available for assistance that are listed below as questions and issues arise as the course of this pandemic unfolds.

      References

        • American Academy of Pediatrics
        Children and COVID-19: State-Level Data Report.
        (Retrieved on July 26, 2020 from)
        • American Academy of Pediatrics
        COVID-19 Planning Considerations: Guidance for School Re-entry.
        (Retrieved on July 20, 2020 from)
        • American Academy of Pediatrics and Children'’s Hospital Association
        Children and COVID-19: State Data Report.
        (Retrieved on July 27, 2020 from)
        • American Academy of Pediatrics and Children'’s Hospital Association
        Children and COVID-19: State Data Report..
        (Version: 8/6/20. Retrieved on August 13, 2020 from:)
        • American College of Cardiology
        ACR MIS-C and COVID-19 related Hyperinflammation task Force. Clinical Guidance for Pediatric Patients with Multisystem Inflammatory Syndrome in Children (MIS-C) Associated with SARS-CoV-2 and Hyperinflammation in COVID-19.
        (Retrieved on July 26, 2020 from)
        • Centers for Disease Control and Prevention
        Health Department-Reported Cases of Multisystem Inflammatory Syndrome in Children (MIS-C) in the United States.
        (Retrieved on August 13, 2020 from:)
        • Fitzgerald D.A.
        • Nunn K.
        • Isaacs D.
        Consequences of physical distancing emanating from the COVID-19 pandemic: An Australian perspective.
        Paediatric Respiratory Reviews. 2020; S1526–0542 (Advance online publication): 30090-30097
        • Fry-Bowers E.K.
        Children are at risk from COVID-19.
        Journal of Pediatric Nursing. 2020; 53: A10-A12https://doi.org/10.1016/j.pedn.2020.04.026
        • Gudbjartsson D.F.
        • Helgason A.
        • Jonsson H.
        • Magnusson O.T.
        • Melsted P.
        • Norddahl G.L.
        • Saemundsdottir J.
        • Sigurdsson A.
        • Sulem P.
        • Agustsdottir A.B.
        • Eiriksdottir B.
        • Fridriksdottir R.
        • Gardarsdottir E.E.
        • Georgsson G.
        • Gretarsdottir O.S.
        • Gudmundsson K.R.
        • Gunnarsdottir T.R.
        • Gylfason A.
        • Holm H.
        • Jensson B.O.
        • Stefansson K.
        Spread of SARS-CoV-2 in the Icelandic population.
        The New England Journal of Medicine. 2020; 382: 2302-2315https://doi.org/10.1056/NEJMoa2006100
        • Heavey L.
        • Casey G.
        • Kelly C.
        • Kelly D.
        • McDarby G.
        No evidence of secondary transmission of COVID-19 from children attending school in Ireland, 2020.
        Euro surveillance: Bulletin Europeen sur les maladies transmissibles = European communicable disease bulletin. 2020; 25: 2000903https://doi.org/10.2807/1560-7917.ES.2020.25.21.2000903
        • Kelvin A.A.
        • Halperin S.
        COVID-19 in children: The link in the transmission chain.
        The Lancet. Infectious diseases. 2020; 20: 633-634https://doi.org/10.1016/S1473-3099(20)30236-X
        • Lee B.
        • Raszka Jr., W.V.
        COVID-19 transmission and children: The child is not to blame.
        Pediatrics. 2020; (e2020004879. Advance online publication)https://doi.org/10.1542/peds.2020-004879
        • Lee J.
        Mental health effects of school closures during COVID-19.
        The lancet. Child & adolescent health. 2020; 4: 421https://doi.org/10.1016/S2352-4642(20)30109-7
        • Menendez C.
        • Gonzalez R.
        • Donnay F.
        • Leke R.
        Avoiding indirect effects of COVID-19 on maternal and child health.
        The Lancet. Global Health. 2020; 8: e863-e864https://doi.org/10.1016/S2214-109X(20)30239-4
        • Munro A.
        • Faust S.N.
        Children are not COVID-19 super spreaders: Time to go back to school.
        Archives of Disease in Childhood. 2020; 105: 618-619https://doi.org/10.1136/archdischild-2020-319474
        • National Academies of Sciences, Engineering and Medicine
        Schools Should Prioritize Reopening in Fall 2020, Especially for Grades K-5, While Weighing Risks and Benefits Retrieved on July 20, 2020 from.
        • National Association of Pediatric Nurse Practitioners
        Prioritizing Return to School for Children in COVID-19 Policy Planning Retrieved on July 20, 2020 from.
        • Parri N.
        • Lenge M.
        • Buonsenso D.
        • Coronavirus Infection in Pediatric Emergency Departments (CONFIDENCE) Research Group
        Children with Covid-19 in pediatric emergency Departments in Italy.
        The New England Journal of Medicine. 2020; 383: 187-190https://doi.org/10.1056/NEJMc2007617
        • Posfay-Barbe K.M.
        • Wagner N.
        • Gauthey M.
        • Moussaoui D.
        • Loevy N.
        • Diana A.
        • L'Huillier A.G.
        COVID-19 in children and the dynamics of infection in families.
        Pediatrics. 2020; (e20201576. Advance online publication)https://doi.org/10.1542/peds.2020-1576
        • Rajmil L.
        Role of children in the transmission of the COVID-19 pandemic: A rapid scoping review.
        BMJ paediatrics open. 2020; 4e000722https://doi.org/10.1136/bmjpo-2020-000722
        • Rothstein R.
        • Olympia R.P.
        School nurses on the front lines of healthcare: The approach to maintaining student health and wellness during COVID-19 school closures.
        NASN School Nurse (Print). 2020; (1942602X20935612. Advance online publication)https://doi.org/10.1177/1942602X20935612
        • Teo S.
        • Griffiths G.
        Child protection in the time of COVID-19.
        Journal of Paediatrics and Child Health. 2020; 56: 838-840https://doi.org/10.1111/jpc.14916
        • UNESCO
        Education: From disruption to recovery.
        (Retrieved on July 22, 2020 from)
        • Van Lancker W.
        • Parolin Z.
        COVID-19, school closures, and child poverty: A social crisis in the making.
        The Lancet. Public health. 2020; 5: e243-e244https://doi.org/10.1016/S2468-2667(20)30084-0
        • Vessey J.A.
        • Betz C.L.
        Everything old is new again: COVID-19 and public health.
        Journal of Pediatric Nursing. 2020; 52: A7-A8https://doi.org/10.1016/j.pedn.2020.03.014
        • Viner R.M.
        • Russell S.J.
        • Croker H.
        • Packer J.
        • Ward J.
        • Stansfield C.
        • Booy R.
        School closure and management practices during coronavirus outbreaks including COVID-19: A rapid systematic review.
        The Lancet. Child & adolescent health. 2020; 4: 397-404https://doi.org/10.1016/S2352-4642(20)30095-X
        • Wade M.
        • Prime H.
        • Browne D.T.
        Why we need longitudinal mental health research with children and youth during (and after) the COVID-19 pandemic.
        Psychiatry Research. 2020; 290 (Advance online publication): 113143
        • World Health Organization
        Rolling updates on coronavirus disease (COVID-19).
        (Retrieved on July 26, 2020 from)
        • Wyckoff A.S.
        AAP news: CDC: Obesity among conditions that up risk of severe COVID-19 disease.
        (Retrieved on July 26, 2020 from)
        • Zar H.J.
        • Dawa J.
        • Fischer G.B.
        • Castro-Rodriguez J.A.
        Challenges of COVID-19 in children in low- and middle-income countries.
        Paediatric Respiratory Reviews. 2020https://doi.org/10.1016/j.prrv.2020.06.016

      Further reading

        • American Academy of Pediatrics
        COVID-19 Planning Considerations: Guidance for School Re-entry.
        (Retrieved on July 20, 2020 from)
        • Association of University Centers on Disabilities
        Frequently Asked Questions (FAQ) 2.0 Re: COVID-19.
        (Retrieved on July 20, 2020 from)
        • Centers for Disease Control and Prevention
        Schools and childcare programs plan, prepare, and respond.
        (Retrieved on July 27, 2020 from)
        • National Academies of Sciences, Engineering and Medicine
        Reopening K-12 Schools During the COVID-19 Pandemic.
        (Retrieved on July 20, 2020 from)
        • National Association of Pediatric Nurse Practitioners
        Prioritizing Return to School for Children in COVID-19 Policy Planning.
        (Retrieved on July 27, 2020 from)
        • National Association of School Nurses
        Considerations for school nurses when providing virtual care.
        2020 (Retrieved on July 24, 2020 from: https://higherlogicdownload.s3.amazonaws.com/NASN/3870c72d-fff9-4ed7-833f-215de278d256/UploadedImages/PDFs/2020_05_13_Considerations_for_School_Nurses_When_Providing_Virtual_Care.pdf)
        • National Association of School Nurses
        Guidance for School Nurses to Safely Send and Receive Resources Between School and Home During COVID-19.
        (Retrieved on July 24, 2020 from)
        • National Association of School Nurses
        Coronavirus Disease 2019 Resources.
        (Retrieved on July 24, 2020 from)
        • Society of Pediatric Nurses
        Information about coronavirus.
        (Retrieved on July 27, 2020 from:)
        • The White House Coronavirus Taskforce
        Coronavirus (COVID-19).
        (Retrieved on July 27, 2020 from)
        • World Health Organization
        COVID-19. IFRC, UNICEF and WHO issue guidance to protect children and support safe school operations. Geneva: World Health Organization; 2020.
        2020 ([Accessed 26 May 2020]. Available from: https://www.who.int/news-room/detail/10-03-2020- covid-19-ifrc-unicef-and-who-issue-guidance-to-protectchildren-and-support-safe-school-operations)