After a year and a half of shuttered schools, many parents and children are hopeful that the days of Zoom lessons are over. Still, worry lingers about the COVID-19 risks kids face in the classroom.

The Centers for Disease Control and Prevention (CDC) says that many K–12 schools with prevention strategies strictly in place, such as mask-wearing and physical distancing, should be able to safely conduct in-person instruction and remain open.

Vaccination is another key strategy for keeping COVID-19 out of schools. In a speech to the nation on September 9, President Joe Biden called for states to require vaccines for all school employees and urged parents to immunize children age 12 and up, who have been eligible for the Pfizer shot since last May.

The Biden administration’s recent vaccination push is a reaction to the relatively low immunization rates in many parts of the country. These are often the same areas where schools districts do not require adults and students to wear masks.

Outbreaks of COVID-19 suggest that more needs to be done in these places to keep kids safe from the highly infectious delta coronavirus variant.

An investigation published September 3 by the Texas Tribune found that at least 45 small school districts across Texas temporarily stopped offering in-person classes as a result of rising COVID-19 cases in the first few weeks of the new school year. Similarly, on September 3, the Sun Sentinel reported that two school districts in Florida were shut until after Labor Day as COVID-19 numbers surged.

About one week after the start of the school year in Montgomery County, Maryland, 1,000 students and staff were quarantined after outbreaks, according to WJLA on September 6. At the beginning of September, Colorado state data indicated that school outbreaks more than doubled in a week, according to the Denver Post on September 3.

Research published August 10 by the Pew Charitable Trust showed that eight states — Arizona, Arkansas, Iowa, Oklahoma, Florida, South Carolina, Texas, and Utah — have enacted laws or issued executive orders prohibiting school districts from requiring students to wear masks.

On the other hand, at least 10 states — California, Connecticut, Delaware, Hawaii, Illinois, Louisiana, Nevada, New Jersey, Oregon, and Washington — and the District of Columbia are requiring all students, teachers, and visitors to wear face coverings in public schools. (On September 10, DistrictAdministration.com provided a state-by-state rundown of masking policies.)

Even in states such as Texas and Florida that have banned mask mandates, some school districts have been pushing back, enforcing policies to keep adults and children safe, according to Reuters on August 10.

“The science certainly suggests that, especially if you live in an area where there [is] a pretty high percentage of COVID positivity, that masking is definitely a very, very effective protective measure,” says Thomas McDonagh, MD, a pediatrician with Northwell Health’s Huntington Hospital in Long Island, New York.

Vaccinations Are Working but More Children Are Getting Infected

While masking certainly helps stop virus spread, COVID-19 vaccines raise defenses to a higher level. These immunizations can provide significant protection to both adults and children 12 and over.

Vaccine trials for children under 12 are ongoing; Peter Marks, MD, director of the FDA Center for Biologics Evaluation and Research, says that results are expected by the end of this year.

But for now, young children are not eligible for the vaccine. “That puts every child under 12 in the high risk category,” says Katherine Williamson, MD, a pediatrician with Children’s Health Orange County and vice president of the Orange County chapter of the American Academy of Pediatrics in California. “So I tell anyone 12 and older, their parents, aunts, uncles to be vaccinated because you’re going to be able to create a safer bubble to live in if you do so. Meanwhile, everyone under 12 can be masking, social distancing, and hand-washing as the next best line of defense.”

A recent CDC study published September 3 in the Morbidity and Mortality Weekly Report (MMWR) showed that delta can spread rapidly in schools when unvaccinated teachers and staff have close, indoor contact with unvaccinated children.

With the rise of the delta and an overall increase in COVID-19 cases in the United States, more children are becoming infected. Since the start of the pandemic, children accounted for 15.1 percent of total cumulative cases; for the week ending September 2, they made up 26.8 percent, according to the American Academy of Pediatrics (AAP). About 252,000 new cases involving children were reported in that time frame, the largest number of such cases since the pandemic began.

A second CDC study, published September 10 in MMWR, showed that rates of COVID-19-associated hospitalizations in children and adolescents, while still uncommon, have also increased. The researchers found that by mid-August, COVID-19 hospitalization rates among children age 4 and under was nearly 10 times the rate seven weeks earlier. The study also found that vaccines helped keep adolescents from becoming very sick; hospitalization rates for unvaccinated children ages 12 through 17 were 10 times higher than for vaccinated kids.

This aligns with data about the power of vaccines to prevent severe COVID-19 and death in the general population. “The incidence of people who have been fully protected via vaccination and become so ill that they are admitted to the hospital ICU, need intubation, or die is extremely, extremely rare,” says Dr. McDonagh.

COVID-19 Symptoms to Look Out for in Kids

The Mayo Clinic says that children with COVID-19 tend to develop mild, cold-like symptoms, such as fever, runny nose, cough, fatigue, muscle aches, vomiting, and diarrhea; many have no symptoms at all. An analysis of more than 350 studies published August 24 in the Proceedings of the National Academy of Sciences found that 46.7 percent of infections in children were asymptomatic, compared with about 35 percent of asymptomatic cases in study subjects of all ages.

While severe COVID-19 among kids is very rare, some infected children can get seriously sick and even die. Confirmed cases of a potentially fatal illness associated with COVID-19 called multisystem inflammatory syndrome in children (MIS-C) have multiplied in the United States since last fall. In October 2020, the number of patients meeting the CDC's case definition for MIS-C in the United States surpassed 1,000. That number doubled as of February 1, 2021. MIS-C cases reached 3,000 as of April 1, and then went beyond 4,000 as of June 2, according to the CDC.

More than 70 percent of these cases have involved children who are Hispanic or Latino or non-Hispanic Black.

In addition to fever, the CDC says children with MIS-C may experience abdominal (gut) pain, vomiting, diarrhea, neck pain, rash, bloodshot eyes, or extreme fatigue.

According to the CDC, 41 children have died from the illness.

Some healthy children who don’t have underlying health conditions that raise their COVID-19 risk can become severely ill, warns Dr. Williamson. “Children’s Health Orange County hospital has a number of very sick kids, most of whom don’t have any preexisting risk factors at all,” she says. “They're just healthy kids, who got the virus and then got really sick.”

McDonagh has treated several children with COVID-19 and a couple who developed MIS-C, but says “Luckily, none of them have had significant long-term consequences to their health.” In a research letter published in JAMA Pediatrics on August 30, scientists in the United Kingdom observed that in 68 pediatric patients who developed MIS-C tied to COVID-19, the majority were fine a year after hospitalization.

Why are most children able to do so well? McDonagh suggests there may be a physiological explanation. “The receptors on their cells may not accept viral infection from this particular novel virus quite so easily,” he says. “There is also a hypothesis that children may be less susceptible because they have some innate cell protection against coronavirus related to being infected more recently and more frequently with the normal cold virus.”

For now, these remain theories, and more study is needed to understand exactly how the virus affects kids.

Do Kids Spread the Virus?

In November 2020, the Association of American Medical Colleges highlighted evidence suggesting that young children do not spread the coronavirus easily. That view appears to be changing as the virus has mutated to become more transmissible.

A large study first published in October 2020 in the CDC journal Emerging Infectious Diseases, found that young people between the ages of 10 and 19 can spread the virus at least as well as adults do, although children under the age of 10 appeared to transmit the virus much less frequently compared with adults.

But a paper presented in JAMA Pediatrics, from July 2020, indicated that very young children could be absolutely brimming with the virus. Researchers discovered that children under age 5 may host as much as 100 times the amount of the virus carried by adults.

“Children spread every other respiratory viral illness known to man,” says McDonagh. “So, I don't think that there's any doubt that children can be spreaders of the virus either within a home or within a contained unit like school.”

Yvonne Maldonado, MD, a professor of pediatrics at Stanford Medicine in California, who specializes in infectious diseases and health research and policy, agrees that schoolchildren have been notorious spreaders of the common cold and flu, so it makes sense they could do the same for COVID-19.

“We know that they don’t handle their secretions very well — they’re more likely to spread them around because they handle their nose and their mouth and they smear things,” she says. Plus, little kids can forget to cover their mouth when coughing and sneezing.

Helping Kids Learn Good Hygiene Habits

It may be challenging to get kids to follow habits related to COVID-19 prevention, like mask-wearing and social distancing, when they feel perfectly fine.

“We need to stress the fundamentals with children,” says Dr. Maldonado. “Should we be masking? Yes. Should we be distancing? Yes, as much as possible. Should we be practicing hand hygiene? Absolutely. So if kids are not doing all of those things, don’t be surprised if you see infections.”

The CDC offers advice on how to help prevent the spread of COVID-19 in schools, including tips on mask-wearing, social distancing, avoiding crowds, and hand-washing. Parents should also check in with children every morning to watch for signs of illness, such as a temperature over 100.4 degrees Fahrenheit or a sore throat, and keep kids home if they are unwell.

Williamson emphasizes that no matter what questions a parent may have, their pediatrician is there to help. “Pediatricians are here to walk you through this because it's a crazy time,” she says. “For parents who have any questions about the vaccine or the disease, your pediatrician is ready and waiting.”

The Tradeoffs Between Remote and In-Person School

A year and a half into the pandemic, discussions about COVID-19 risk in schools tend to compare the potential danger of coronavirus exposure against a child’s academic, social, and emotional needs and the stress on family life caused by remote learning.

Like many parents, Dan and Karina Schulte have had concerns about sending their child Elias off to attend third grade in person this year — even on a part-time basis. While fully aware that more children have been getting COVID-19, they also believe their school in the Seattle-area is taking every possible precaution: Teachers and staff are fully vaccinated, the building is disinfected regularly, and the school is enforcing a mask mandate. There is also an online dashboard so parents can track if anyone gets infected or is quarantining.

The Schultes are extra cautious because their child lives with physical challenges that put him at higher risk of becoming seriously ill if he does get infected. Weighing the tradeoffs of in-person versus at-home learning has been especially difficult.

“The pandemic has been grueling for us,” says Dan. “It is very hard to find caregivers right now so most of the time it’s just Karina and me taking care of Elias. His special needs require a lot of extra care. With him out of school, he misses out on therapies and education. He really needs direct contact especially with physical therapy. Moreover, Karina and I desperately need respite. School is huge — for his needs and ours.”

The American Academy of Pediatrics offers more information about how to protect students at Safe Schools During the COVID-19 Pandemic — HealthyChildren.org.