If you are under the mistaken belief that Covid-19 neither harms children nor can be spread by them, asking them to wear masks probably doesn’t make any sense. However, we know that Covid-19 does in fact pose substantial risks to children—though thankfully far less commonly than among adults—and that they can and do spread it.
Given that, it’s bizarre that the World Health Organization continues to recommend against masks for children under the age of 5, the last remaining demographic in whom effective Covid-19 vaccines are not yet available. Meanwhile, the US Centers for Disease Control and Prevention and the American Academy of Pediatrics recommend them for children ages 2 and up, when possible.
Why the difference? The ability to keep up with the data, it seems. Or else agility. The CDC’s last update on this was January 28, 2022. The AAP’s last update on this was January 6, 2022. The WHO’s most recent guidance on this is from August of 2020.
August 2020?! That’s the stone ages, in terms of this pandemic. Given how much we’ve learned since then, the WHO either needs to remove their guidance immediately or update it. They either need to get up-to-speed on data or get out of the guideline game.
There’s reason for hope. Last summer, I asked WHO experts whether they would revise their pediatric mask guidance. They told me the following: “As with all its guidance, WHO constantly re-evaluates the mask guidance in light of new research and findings. Masks as part of a comprehensive strategy help to reduce the spread of SARS-CoV-2. WHO and UNICEF issued guidance on the use of masks in children and have made recommendations by age as well as considerations for younger age groups. There are factors for mask use in young children that need to be considered when decision makers set policies….WHO/UNICEF will review the mask advice for children in 2021.”
Then nothing happened.
I recently checked my calendar and, as you may be aware, it’s now 2022. So, I asked again. Initially I was told there would be no update. Surprised, I asked for clarification, as this seemed patently absurd. I then was told there would be an update very soon. On February 1, 2022, the WHO told me that, “the evidence-based process of updating the guidelines on masks in children has been undertaken in collaboration with UNICEF and is under finalization, at final clearance stage.”
They need to hurry up. This is not some hypothetical exercise. There is urgency to act at something other than molasses pace. In the United States alone, there have been over 105,000 pediatric hospitalizations either directly or indirectly caused by coronavirus (of which a substantial portion if not a majority were not merely “incidental” detections at the time of hospitalization for other reasons) and over 1,239 pediatric deaths have occurred. The WHO, of course, serves member nations globally, including parts of Africa where pediatric Covid-19 outcomes are clearly worse than in wealthier nations and where widespread vaccinations for all ages are even further from becoming a reality than they are here in the US. Indeed, we still do not have effective vaccines for children under the age of 5 anywhere. You’d think advocating for mitigation and minimizing of Covid-19 among young children would be a high priority.
Why did the WHO recommend against masks for children under age 5 in the first place? Two reasons, both of which are now understood to be incorrect.
First, as mentioned, back in 2020, we knew less about pediatric Covid-19 in terms of spread and complications. Few pediatric hospitalizations or deaths had occurred at that time, and important complications like Multi-Inflammatory Syndrome in Children (MISC) had only recently been recognized. (We now know that thousands of young children have been hospitalized with MISC).
Second, the WHO bought into the notion that masking young children might actually be harmful. In their guidance, they wrote that their advice was “motivated by a “do no harm” approach and considers: childhood developmental milestones, compliance challenges and autonomy required to use a mask properly.” Indeed, we now know these concerns are largely unfounded. Perpetuating them not only borders on fear-mongering, but frankly it’s public health malpractice because it fails to assess the do-no-harm standard to not masking.
Mask use has been associated with keeping schools and daycares open (an important goal) and no lasting impact on social or intellectual development has been linked to intermittent mask use by young children. And even if some signal of that were to emerge (which I’m sure some shady researchers will again try to produce), we would have to weigh that against the alternative: more Covid-19. Enough children suffer and enough spread it to family members, some of whom die, that we have to consider the developmental and educational impact of that. Losing a parent or caregiver is exceedingly disruptive to a child’s long-term academic achievement. Choices like masks for kids are not occurring in a disease-free vacuum. They’re being made during the deadliest pandemic in over a century.
In fairness to the WHO, its guidance acknowledged that some of its member nations might choose policies allowing for mask use in children as young as age two. But again, it emphasized its concerns around the harms without acknowledging any benefit. The guidance stated that young children wearing masks need “appropriate and consistent supervision, including direct line of sight supervision by a competent adult and compliance need[s] to be ensured, especially if mask wearing is expected for an extended period of time.” What could be more obvious than that? This was like saying “don’t drive because kids might not be wearing a seatbelt.” The better posture would have been to say, “don’t drive if the kids aren’t able to wear a seatbelt.” The WHO got it backwards.
The problem is not that these guidelines were ever published. The problem is that they remain in effect 18 months later and have been incorrectly cited by people seeking to politicize mask wearing and claim that parents who want to protect their unvaccinated kids from Covid are doing harm to their own.
And that’s the crux of the issue. The WHO asserted that its 2020 pediatric mask guideline reflected a “do no harm” approach. However, it did not actually, because it carried out the analysis asymmetrically. Most, if not all, proposed mitigation measures carry both benefits and harms. If you only acknowledge the harms of action, and ignore the harms of inaction, you’re doomed to end up with inadequate assessments and are at high risk of reaching faulty conclusions. Are there harms from not masking? Certainly. Are there harms from masking? Perhaps. In reality, the WHO failed to take a “do no harm” approach. Instead, it took a “do no harm reduction” approach. It’s time for that update.
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