Are face masks safe for children?

* What then are the precautions that parent need to take for small children?

How does one force a child with hands that are never still to wear a face mask? It’s a question that has been troubling parents for a while now. After health experts decreed that covering one’s nose and mouth with a mask was one of the best ways of tackling Covid-19, those with small children felt particularly uneasy.

Take the case of Smita Sen (name changed). A resident of Baharampur in West Bengal, Sen has been struggling to ensure that her three-year-old son keeps his mask on. But the boy either pulls it off, or has trouble breathing when he is forced to wear one.

Sen has now heaved a sigh of relief. The World Health Organization (WHO) and Unicef have said in a recent statement that children up to the age of 5 years need not wear a mask in normal circumstances. For children aged 6 to 11 years, a face mask is needed when there are risks — such as when they have underlying diseases, an intensity of disease transmission in the neighbourhood, sports meets and elderly relatives at home. Those aged 12 years and more should wear face masks, like adults, says the August 21 advisory.

Though some have doubts about the advice, based on studies and recommendations from an international expert group, many have welcomed it.

“It is really difficult to instruct kids below 5 on the proper use of a face mask,” says Sanchita Roy, a Kolkata-based paediatrician. “Because of problems such as discomfort, irritation and difficulties in breathing, most children refuse to wear a mask,” she says.

“They should be restricted to the home. And when taken outside, safe distancing and hand washing under the supervision of adults should be encouraged,” she adds.

Roy says she has treated children who wore masks and developed breathing difficulties when they indulged in energetic activities. “The retention of carbon dioxide or improper ventilation may cause certain blood parameter changes which may lead to headaches, poor concentration and sometimes an allergic cough,” she says. The two global agencies also cite a small study, published in the journal Clinical Research in Cardiology in July 2020. The study, which looked at 12 healthy adults, suggests that ventilation, cardio-exercise capacity and comfort of individuals got reduced by surgical masks and substantially so by the use of N95 respirator masks. They refer to several other studies to note that “warmth, irritation, breathing difficulties, discomfort, distraction, low social acceptability and poor mask fit were reported by children when using masks”.

Agnimita Giri Sarkar, consultant pediatrician at the Institute of Child Health in Kolkata, has seen how badly handled face masks by younger children can act as a potential contaminant for viruses. In rare circumstances, they may hide the early symptoms of respiratory illnesses or even asphyxiation, she says.

She, however, also voices caution. “It is also important to note that in countries such as India, with a high population density and joint families, younger children can act as the transmitter of [Covid-19] to others, particularly those with co-morbidity and advanced age,” she adds.

Of course, a mask becomes a necessity when a child is in an area where there is a high transmission of the virus.

“For children between the ages of 6 and 11, I think the recommendation is to wear a mask where there is widespread transmission, especially in parts of New Delhi where [a serological prevalence of] 34.7 per cent [was noted in participants aged 5-17 years] against the Covid-19 virus, thus indicating a relatively high level of disease spread,” points out Anish Ray, consultant paediatrician at the Cook Children’s Medical Center in Texas, US.

Additionally, Ray adds, there has to be a case-by-case determination, because not all children in the same age group have sufficient developmental skills and maturity to safely and appropriately use a mask.

Some experts, however, believe that children cannot do away with masks. “In spite of having high viral load [children] might not have any symptoms,” warns Nirmal K Ganguly, former director general of the Indian Council of Medical Research. “[They may] transmit [the infection] to their teachers, grandparents and elderly service providers,” he says. “Mask wearing is not only to protect oneself but also to protect others. With new data [showing] children having the infection, too, I would encourage them to wear a mask,” he holds.

Eminent virologist Thekkekara Jacob John, an emeritus professor and former head of clinical virology at the Christian Medical College in Vellore, also recommends the universal use of face masks — “for all ages including children who are able to understand and tolerate masks”.

He is also sceptical about a “cut-off” line at 5 years, pointing out that a day after a child’s fifth birthday, his or her development is unchanged. “Children tend to imitate grown-ups and may tolerate, or even like, wearing masks, from an age younger than 5,” he points out.

According to him, children should be taught the value of mask use in the time of Covid-19, just as they are made aware of the need for cleanliness, brushing their teeth, washing and bathing and so on.

The WHO-Unicef advisory also stresses that given the lack of evidence about the impact of masks on children, policy makers should ensure that their guidance does not “negatively impact” development and learning outcomes. They should also consider the feasibility of implementing recommendations in different social, cultural and geographic contexts.

“Do no harm: The best interest, health and well-being of the child should be prioritized,” the advisory states.

Sanjeet Bagcchi is a physician and independent writer based in Kolkata

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