As state and local officials look to reopen schools in the fall, pediatricians and primary care doctors will likely field a lot of questions from worried parents about whether it's safe to send their children back to classrooms amid the coronavirus.
Will children have to wear masks? Will sports and after-school activities be safe? And how do you keep six-year-olds from hugging their friends and touching their faces?
The challenges of reopening K-12 schools in the fall was the subject of a recent viewpoint published in the Journal of the American Medical Association. The piece, which outlines measures that schools should take to minimize risk, was written by Joshua Sharfstein, M.D., vice dean for Public Health Practice and Community Engagement for the Johns Hopkins Bloomberg School of Public Health, and Christopher Morphew, Ph.D., of the Johns Hopkins School of Education.
"It’s important for people to understand that there’s nothing that is perfectly safe. No activity, including staying home, is perfectly safe," Sharfstein told Howard Bauchner, M.D., editor-in-chief of JAMA, in a recent interview.
RELATED: Cigna: COVID-19 leading to deferred pediatric care for conditions like epilepsy, asthma
School, state and local officials need to be honest with parents about the risks and the measures being taken to keep the risk as low as possible, he said.
"At school, basic screening is probably appropriate," Sharfstein said.
Schools should use paraprofessionals—such as nursing aides and other trained staff— to screen children quickly on arrival, make hand-washing and other supplies readily available and adopt schedules for cleaning high-touch areas and disinfecting classrooms with appropriate protective equipment for maintenance staff, the researchers said in the viewpoint.
Following guidelines from the Centers for Disease Control and Prevention, protocols at schools will likely involve spacing classroom desks six feet apart, keeping groups of children together throughout the day to limit mixing, staggering drop-offs and pickups, closing common areas and canceling extracurricular activities that require close contact.
Staff and older students should wear cloth face coverings, particularly when it is difficult to maintain distancing.
"In terms of masks, we need to recognize that some ages it’s just not possible," he said. "There needs to be a strong understanding with parents that if anyone at home is sick then the child doesn’t come to school as the child could be asymptomatic."
Parents need to do a check-in every morning to see whether their children have symptoms and whether other family members are ill at home.
The jury is still out on whether children are more or less contagious than adults, Sharfstein said, with recent research suggesting kids are less likely to spread the virus.
Sports and after-school activities will need to be considered on a case-by-case basis, with the understanding that after-school programs are beneficial to parents who need their kids to have supervision until they get off work.
"From a public health standpoint, each one has to be analyzed on its own and asked if it can be made safer. With choir practice, that activity may not be in the cards this year. Other types of clubs and activities could exist with social distancing in areas with a low level of community transmission," Sharfstein said.
RELATED: Emanuel: 'Immunity passports' could help open economy, but science still needed
Despite the risks, reopening schools this fall is an urgent national priority, the researchers said.
"What kids get from schools is not just the three 'Rs.' With schools closed, children have lost access to health services through school-based health centers. More than 20 million children rely on school breakfast or lunch," Sharfstein said.
Attending school impacts a child's social and emotional development, he said.
"Teachers and other school officials recognize one in five cases of concern for child abuse. All those cases aren’t being reported now, he said.
School district leaders will need to consult with state and local officials, parents, teachers unions and other employees to develop a strategy for reopening. That strategy will need to focus on facility needs, transportation, staffing and education curricula.
"It’s like an emergency response decision-making structure that schools should adopt," Sharfstein said.
RELATED: Pediatric practices struggle to adapt and survive amid COVID-19
School districts will need to be prepared to adopt a hybrid approach that combines physical in-class learning and remote learning, especially if there is a spike in COVID-19 cases in their communities, the researchers said.
Some parents and students will view the risk as too high and should have the opportunity for online learning, Sharfstein said.
There are many kids who lack access to broadband internet. School systems should make on-site education a high priority for kids who experience barriers to remote learning, students who receive special education services or nutritional support at school and younger children.
"One approach that districts need to think about is the idea that some children at some age levels learn better remotely. Think about high-schoolers versus elementary-age school children. We know elementary-age children don’t do as well with remote learning," Morphew said.
Both researchers said massive funding from the federal government will be needed to give states and local school districts the resources needed to put all these measures in place.
"The staffing needs, the facility needs, the technological needs, all of these things are labor-intensive and resource-intensive. Keeping kids in different groups will require more teachers. We've seen evidence that this strategy works in Norway and Finland as they have reopened," Morphew said.