Mask Exemptions

Back to school during a pandemic has brought many new considerations this year. Parents and schools have struggled with how to safely bring kids into classrooms and how to provide options for those who are not able to safely return to class. One of the best methods we have found to increase safety in our communities is to have the majority of people wear a mask. Mask exemptions from parents who want their student to be allowed to attend school without a mask are a new request this Fall.

Some of the requests for an exemption are for a clear cut "yes" or "no" indication. Some requests are difficult for many pediatricians to weigh risks and benefits given the myriad of circumstances and all the unknowns about COVID-19.

I've been hesitant to write for mask exemptions, especially since our community COVID-19 rates are high currently. It is tempting for some students who really need to be in school and have trouble wearing masks for various reasons, but it's hard to balance the need with the risks that they would pose to themselves and others.

The hardest thing with exemptions is that masks are needed to protect others. People not wearing a mask are putting not only themselves at risk, but others. This isn't so much a personal decision as a community safety measure.

Maybe when our area's COVID-19 rate decreases I will feel differently, but at this point it is hard to put everyone in the school at risk for a student who cannot wear a mask.

Who is to say when it's okay to put others at risk?

Reasons for mask exemption requests

Kids won't tolerate them

Many parents fear that their kids will resist wearing a mask. Some parents are afraid kids will play with the mask or remove it frequently.

These behaviors increase the risk of germs on the mask and their fingers.

The good news is that we can teach our kids how to safely clean hands before and after touching the mask.

Kids are generally used to following instructions. We can teach them and patiently remind them. They will learn, much like they learn to keep shoes on at school or to not unbuckle their seat belt while the car is moving. Some require more training than others, but most can learn.

There are some with neurocognitive differences that make this more difficult, but with the help of professionals, most can learn to safely wear face coverings.

I've written many tips to help kids learn to safely wear masks here.

Kids will be afraid of people in masks

I was concerned back in March when I started wearing a mask throughout the day in my office, but kids didn't skip a beat for the most part.

Infants and toddlers don't seem to mind at all - some even seem less threatened by me when I examine them.

Some preschoolers and young school aged kids had questions early on, but by now most have seen their parents wearing them. It really isn't hard to explain to them how the mask helps us keep everyone safe from getting sick. They often like the idea of being a superhero and wearing a mask.

I now joke with them that I play dress up at work in my mask and face shield. Then I tell them how the shield protects me when I have to look at their throat because they'll take off their mask. We talk about how germs enter our body through eyes, nose and mouth, so I have all covered with my shield and mask.

We all adapt to new things and masks are no different. Just like they get used to someone in new glasses or a beard, they adjust to people wearing masks.

Most kids "don't get that sick"

COVID-19 is not just the flu.

Many kids don't seem to get very sick with coronavirus infections, but we're playing roulette with who might. Some kids have died, and not all of them had pre-existing conditions.

When we have a typical influenza season, people have an option to protect themselves with a vaccine. COVID-19 does not yet have that option. We rely on others to not spread it. Masks and physical distancing help, but we all must participate for these to work.

When people are infected with COVID-19 they can spread the virus for up to 14 days without symptoms. Influenza typically spreads only 1-2 day before symptoms develop and up to 5 to 7 days after becoming sick. It's easier to identify and isolate people infected with influenza. COVID-19 can spread throughout the community without detection longer, allowing more people to be exposed and then share with others before being identified.

A typical flu season kills 12,000 – 61,000 annually since 2010. COVID-19 has killed well over 180,000 Americans in only 8 months. Analysis of current data shows that COVID-19 is 10 times deadlier than the flu, but this number will change as we learn more. Numbers for kids being killed from COVID-19 are lower than for adults, but they can share with others at a higher rate if they're not wearing masks.

Long term effects - largely unknown

So far it appears that kids don't usually get very sick with COVID-19 infections. That's good news.

While they usually have asymptomatic COVID-19 disease or very mild symptoms, some do suffer more significant illness.

For whatever reason some children develop Multisystem Inflammatory Syndrome in Children (MIS-C) weeks after they seem to recover, or even if their infection was not recognized.

We don't know long term complications that they may face.

Death or recovery are not the only outcomes of infections.

There are reports of adults and children showing prolonged symptoms after the initial COVID-19 infection. We have a lot yet to learn about these prolonged symptoms.

Heart complications are being identified in previously well children and young adults after recovery from COVID-19 infections. Because of this many physicians are recommending and several states are mandating medical clearance prior to return to play for student athletes.

In addition to those who are now calling themselves "long haulers" we don't have a clue as to what will happen years from now.

Many viruses that we've lived with for generations have known long term effects.

• Chicken pox can cause painful episodes of shingles many years after apparently recovering from the infection. This occurs in about a third of all who have had the infection. About 10% of those with shingles have debilitating long term pain.

• Polio can lead to late effects such as muscle weakness, chronic pain and trouble breathing.

• Measles can lead to Subacute Sclerosing PanEncephalitis (SSPE) many years after apparent healing from the acute infection. This is rare, but always fatal.

• Several viruses can lead to cancer years after infection.

  • HPV - cervical, head and neck cancers.

  • EBV - lymphoma and head and neck cancers.

  • HBV and HCV - liver cancer.

We know about these late effects because generations of people have been infected and studied. COVID-19 has not even been an infection in humans for a full year.

There's a lot we need to learn.

It's not just the kids

We now recognize that kids can share their infections with teachers and school staff or bring it home to their families. Any of these people might have higher risk factors.

Children have been found to spread COVID-19 without symptoms or with very mild symptoms that could be dismissed as a garden variety cold or allergies.

We cannot put the teachers, staff, other students and all of their families at risk.

Who should not wear a mask?

Per the AAP, children under 2 years of age should not wear a mask due to safety concerns.

Anyone who is unable to remove the mask when necessary, whether due to a physical or mental condition, should not wear a mask.

Because masks help stop the spread of COVID-19, the people mentioned above should avoid public areas whenever possible. This is difficult because many need to attend daycare so their parents can work.

One consideration is that it seems that young children do not spread COVID-19 as readily as older children and adults, so their mask use may not be as much of a concern to others. This is still under investigation and may change, but current data supports that children under 2 years of age do not spread this infection easily.

What about medical conditions?

It is recommended that anyone with asthma, COPD, or most other chronic medical conditions wear a mask. They may be especially vulnerable to illness so should protect themselves and others by wearing a mask.

Hearing impaired

Those with hearing impairments may struggle to communicate with people who are wearing a cloth mask due to the inability to read their lips. If you routinely interact with people who are hearing impaired, consider using a mask with a clear center.

For those who wear hearing aides, the mask may displace the aide or the aide may make the mask uncomfortable. There are several suggestions in this post from Hear Soundly.

Breathing problems

Masks do not cause retention of CO2 or decreased oxygen. They don't. Surgeons would not be able to perform complicated operations for hours wearing a mask if these issues occurred. Don't believe this propaganda. It's simply too easy to prove to be false.

​If you have asthma and worry that a mask will interfere with breathing: no need to worry! See the American Academy of Allergy and Immunology Mask Statement for those with allergies and asthma.

What about anxiety and PTSD?

People with sensory issues, anxiety or a history of trauma can be triggered by something over their face. Even those without a history of anxiety can have trouble tolerating face coverings at times.

What can someone who has anxiety about wearing a mask do?

• As with many anxieties, identifying the issue for what it is can help conquer the attack.

• Deep breaths can help, but the mask may increase the feeling of air hunger if it sucks into your mouth when you inhale. Go to a safe place away from others to remove your mask and take deep breaths.

• Tell yourself that you can breathe, it’s just that your body is saying that you can’t. You can breathe. You are safe.

• Use a mask made out of a material that is not too flexible. I find these to suck in as I breathe, which can lead to the feeling of air hunger.

• A mask bracket may also help keep the mask from touching your face or sucking into your mouth when you inhale deeply.

• Take mask breaks as needed. Go to an open space and remove your mask.

• Focus on the greater good. We wear masks for others. By wearing a mask you are helping other people. (It's amazing how helpful it is to focus on the fact that what we're doing is for someone else!)

• Try hypnotherapy. Here's a link to a free hypnotherapy session.

Working with a therapist can help desensitize these feelings. If sensory issues are a problem, work with an occupational therapist.

More tips on Wearing Masks.

Bullying

Bullying risks need to be taken into account when trying to decide if a mask exemption should be granted.

We all know that bullying is a problem in our schools. One of the things that makes kids a target is being different.

If kids are not wearing the mask that the school is requiring everyone else to wear, other students may take it upon themselves to make this an issue.

I certainly don't endorse bullying and would like to believe that teachers could control it, but we all know that students find ways out of a teacher's earshot to bully and tease.

If we can find ways to help a student wear a mask, it not only will help protect everyone from getting sick, but it might help protect them from being a target due to standing out and being different.

Special Needs Children

This is probably the area that is most difficult to assess.

Children with special needs often struggle with sensory issues, which can lead to problems with face coverings. They may lack the neurocognitive abilities that other children can use to work on the sensory issues or anxiety with family and professionals.

I can easily see two sides to this issue, but the CDC's recommendations state that masks should be worn. A screen shot from the page is shown below. It cuts off the top of the columns, but the first column is for "Masks recommended" and the second is "Masks may be considered." In this image, the column for "Masks recommended" is checked.

The "adaptations and alternatives" link states

This advice about wearing masks may include working with a therapist for anxiety issues or behavioral compliance or an occupational therapist for sensory issues. See Wearing Masks for several suggestions.

Pro-exemption: the need for school

Children in special needs classrooms are among the ones most likely to benefit from in person instruction and are less likely to be able to learn well virtually.

Families of these children need a break. They love their children, but these children often take constant monitoring. It can be exhausting to be sure they are safe at all times. The issues that make them special needs in school often leave them unable to do routine self cares that other children their age can do. Parents have had to do everything for their children for months. They need a break.

Con-exemption: easy spread

Children in special needs classrooms are often high risk of getting significantly sick due to medical conditions. These students need extra precautions protecting against all contagious infections. Many have genetic conditions that not only affect their learning and behavior but also affect their heart, lungs, or their immune systems. Some have neuromuscular problems that put them at risk for hospitalization with what would be otherwise mild illnesses.

Special needs classroom students often have behaviors and needs that increase the spread of infections that they have. These may include mouthing objects or fingers, yelling, spitting, or needing close physical assistance throughout the day.

These students also need more personalized care than other students. Teachers and aides often work physically close with them, so if students are not properly masked, the staff and are more at risk.

Do we really want a classroom where the children do not wear masks?

If one student brings COVID-19 into the class where masks are not required, it could easily spread from child to child or child to teacher, and then to their respective family members.

Even though the special needs classes tend to be small, all of the children live with others. We cannot require that everyone in their homes live in a bubble. Parents may work outside the home. Siblings may attend school, play sports and participate in activities. They live their lives. Every one of these family contacts increases exposure to the student and everyone that he or she is around. That risk increases without masks.

If a high proportion of people in one room are not masked, it is a set up for rapid spread of COVID-19. Many children in special needs classrooms may resist masks due to sensory issues. Others may not be able to wear them because they can't safely remove a mask due to physical or neurological limitations. Due to the many reasons these students may not wear a mask there is a high potential for many to be unmasked in special needs classrooms if mask exemptions are allowed in a class.

This is a set up to become a hotspot within the school, leading to further spread throughout the school community.

If wearing masks is not possible for all or some of the students, it may require finding better ways to virtually teach students with special needs.

For more

Best mask use

• How NOT to wear a mask (NYTimes)

• Do not use masks with valves

• For those who are hard of hearing, use a voice to text app, such as Google's Live Transcribe

• The Ultimate Guide to Homemade Face Masks for Coronavirus: Ultimate facemask materials

Concerns About Masks

• ​American Academy of Allergy and Immunology Mask Statement for those with allergies and asthma

• Children's Mercy decision tree for mask exemption

• For tips on getting kids to wear a mask, see Wearing Masks