Donna Hallas, PhD, PPCNP-BC, CPNP, PMHS, FAANP, FAAN 

On the topic of ‘return to school’ this year, anxiety abounds for parents and children, as well as teachers, school staff and nurses, nurse practitioners (NPs), departments of health and legislators.

 Since school is considered “the work of children,”

 we must carefully consider all aspects of ‘return to school’ in light of the current, unprecedented COVID-19 pandemic. Many compelling questions emerge, but first and foremost the question to address is: 

Can children return to school and be in classroom environments that assure health and well-being for all?

The National Parent Union conducted an online COVID-19 survey of 500 parents with children from kindergarten through 12th grade on May 4 and 5, 2020.

 Lowe’s data revealed a significant level of anxiety among parents concerning return to school for their children. A 

 article reported that 6 of 10 parents are considering continuing with home learning rather than sending their children to school in Fall 2020.

 Some of the parental anxiety and decision making by parents may be attributed to uncertainty as the pandemic remains a viable threat throughout our country.

Planning, testing and masks are a critical component for safe return to school

Guidance from the Centers for Disease Control and Prevention (CDC) for opening schools was posted on the CDC website on March, 19, May 19, June, 3, and July 23, 2020.

 The guidance emphasizes the importance of school officials and administrators collaborating with local health officials for decision making regarding return to school and decisions about closing schools, while the most recent statement did stress the importance of reopening schools. The initial interim CDC guidelines

 did not address two major issues, masks and testing, that must be resolved either locally, or nationally by implementation of best available scientifically based health safety measures prior to any child’s/adolescents return to school. However, the CDC guidance on July 23, 2020 does recommend masks for children and staff in school settings, except those under 2 years old, and those with some medical conditions. Since wearing masks has been met with controversy, the work of health care professionals (HCPs) is to gain the support of parents, children and school personnel to wear masks during school. And, while recommendations presented in this paper are consistent with CDC guidelines and supports wearing masks, it also provides more stringent considerations for testing school personnel and children. All HCPs realize the ever evolving and changing health care recommendations as the pandemic moves across the country and the world. Thus, what is considered best practice today based on the available evidence, may be shown to be incorrect tomorrow. Making reasonable changes to tackle the twists and turns that emerge every day in this pandemic is a major challenge. Health care professionals at the local, state, regional, in helping non-HCPs make sensible decisions based on scientific data to protect all individuals. Return to school decisions must be based on the science with the overall goal of the health and well-being of the children/adolescents, the school personnel and the community as a whole. One size and one decision will not fit all.

The CDC guidance on COVID-19 from July 23, 2020 supports using “cloth face coverings” to prevent the spread of the COVID-19 virus, and includes in their practical recommendations that schools put “cloth face coverings on school supply lists and provide cloth face coverings as needed to students, teachers, staff, or visitors who do not have them.”

 Indeed, the scientific evidence from COVID-19 public health measures supports wearing masks as the new norm for all adults and for all children older than 2 years. Thus, we believe that wearing masks is an essential component of safe return to school. However, children with chronic illnesses, including pulmonary conditions, and those with disabilities may be advised by their physicians and NPs, not to wear face masks. Thus, some protection for children, who are too young to tolerate wearing a mask or are unable to wear masks, may be provided by other children and school personnel who can safely wear face masks in school settings.

The CDC guidance of July 23, 2020 also states that “[The CDC] does not currently recommend universal symptom screenings to be conducted by schools.”

 School NPs and school nurses are educated on public health screening measures and are ideally suited to appropriately screen students and all school personnel prior to entering school for the purpose of preventing exposure of individuals with COVID-19 or any communicable disease symptoms from spreading the virus to contacts at the school. The value of having a school nurse for every school was supported by the AAP policy statement in June 2016.

 In this pandemic, the school nurse is an essential part of the healthcare team (eg, private practice physicians, school based health centers, community clinics, and the department of health) overseeing the health of the children and school personnel and should be employed in every school.

Another major concern identified in the original CDC guidance

 is the recommendation to close schools for 2 to 5 days when there is a confirmed case of COVID-19 in the school system. Opening and closing schools for 2 to 5 days will be disruptive to everyone. Testing prior to return to school may prevent schools from opening and closing in a chaotic fashion.

Plans to reopen schools must be based on local and state public health data as well as primary and secondary prevention strategies that minimize the potential for viral spread, and avoid a cycle of frequent opening and closing of school systems due to outbreaks of COVID-19.

 The authors believe that testing of students and school personnel prior to reopening schools is the cornerstone of primary and secondary prevention strategies. And while the most recent CDC guidance does not recommend universal testing of children and staff, it however, proposes other testing strategies based on local and state data.

When the pandemic began, data from other countries led health care providers to believe that children were less affected by COVID-19 but may be asymptomatic carriers.

However, as the pandemic spread in the United States and Italy, there were news reports of chronically ill children hospitalized with severe symptoms. The most troubling occurrence is the new presentation of the COVID-19 complication of the syndrome, Multisystem Inflammatory Syndrome in children (MIS-C).

 The etiology of MIS-C remains unclear. According to reports from the CDC, children who developed MIS-C may have been infected weeks before the appearance of MIS-C symptoms, and/or were symptomatic carriers.

Thus, based on these presentations of COVID-19 in children, testing strategies for children must be considered on all levels to protect all children, school personnel, and the communities in which they live. As of this writing, data for widely testing children for COVID-19 in the United States is non-existent.

Innovation is an outcome of a crisis. New, non-invasive methods for testing for COVID-19 in children should be developed. Saliva sample testing may be a reasonable solution that can be developed, and, as of this writing, is under investigation as a point-of-care test.

Once testing policies and methods are in place, only then can we proceed with developing other policies that address a safe school environment for children and adolescents, and all school personnel that work every day to educate and care for our children/adolescents.

Screenings are critical to safely reopen schools

Children have been out of school since March 2020 and may not have had their usual access to health care throughout this pandemic. Screenings to identify problems in physical, emotional, social, and behavioral health are a critical strategy for the design and implementation of effective strategies for healthy children. Thus, we encourage all HCPs, including school nurses, to assume a leadership role in the design and implementation of screenings for the identification of children and school personnel who may present with problems that may have arisen during stay-at-home orders (eg, anxiety, school phobia, etc.).

Screening is a critical part of the process for prevention of transmission of COVID-19 within school systems. An innovative, reliable method for screening children and school personnel prior to going to school each day should be implemented. Some health care systems and other clinical practices have already implemented the use of a web-based application or ‘app’ that can be used to screen for temperature and emerging symptoms one-hour before reporting to work each day. This screening tool asks the individual to report the morning temperature, and also asks other pertinent questions about symptoms and possible exposure to an individual with COVID-19. If negative, the employee reports to work. If any portion of the screening is positive, the individual does not report to work that day. For parents who do not have access to cell phones or apps on their devices, a plan should be in place for the parents to call into the school and report the information to be reviewed by the school nurse prior to the children leaving for school. Once at work (school) and before entering the workplace (school environment), a second temperature screening is recorded. Such an app for school-based screenings for children and school personnel can easily be developed and implemented as best practice for early identification of possible COVID-19 exposure and/or infection for healthy children.

It has been theorized that COVID-19 viral shedding may persist for longer periods of time through the gastrointestinal tracts of in children.

 It is believed that children may be asymptomatic carriers and may shed the virus for days or even weeks, but too little testing has been done. Schools must be vigilant in preparation of the bathroom space of children and school personnel, preparing for the worst-case scenario. It is important for school systems to be proactive, rather than reactive. Leadership of school nurses and nurse practitioners is essential in policy preparation and enactment of policies for bathroom use.

Frequent cleaning and maintenance of modern bathrooms will reduce risks shedding and must be instituted prior to opening schools, and continue throughout the school day. Measures to help children become comfortable in the bathroom must be part of the curriculum. Soap, running water, and a clean toilet must be established.

 Bathrooms may increase risk of disease transmission without structural change (proper toilet design, adequate soap and water, frequent cleanings). Proper implementation of a plan will enable children and staff to better understand how to prevent other diseases (including influenza and other common gastrointestinal diseases), which should also help change attitudes and establish new norms.

COVID-19 brought to the forefront nationwide educational inequality. As HCPs, we know the importance of being lifelong learners and the importance of early childhood education and continued excellence in education throughout the K through 12 years. It was distressful to hear many parents report that their children did not have access to computers, tablets and/or the internet at home to continue their education virtually. To achieve meaningful societal change, social justice and educational parity, we encourage educators, parents, and all community members to analyze the local educational needs and to plan accordingly to meet the needs of all students.

As Erik Erickson said, “School is the work of children.”

 We value the education our children receive throughout the US each year preparing the children to develop into healthy, kind, valuable, innovative and productive members of society in whatever careers and professions they choose. The immediate closing of schools at the onset of the COVID-19 pandemic has further enlightened everyone on the value of educators and the school systems. All HCPs want children to return to school safely and free of the threats of contracting COVID-19 within the school environment. Thus, our recommendations are based on the best available evidence as of this date and time. Screening, non-invasive testing, masks for all children over 2-years old, eye protection, social distancing, cleaning, transportation, and bathroom use are critical to the health and well-being of the children, all school personnel, their parents, family members and the community in which they live and grow.

1. Lowe, B. New poll: Two-thirds of parents support keeping schools closed ‘until they are certain there is no health risk’. Published May 11, 2020. Accessed June 3, 2020. 

https://www.the74million.org/new-poll-two-thirds-of-parents-support-keeping-schools-closed-until-they-are-certain-there-is-no-health-risk/

2. Erikson, EH. Childhood and society (2nd ed.). 1963. W. W. Norton & Company.

3. The Editorial Board. How to reopen America’s schools. The New York Times. Published June 6, 2020. Accessed June 17, 2020. 

https://www.nytimes.com/2020/06/06/opinion/coronavirus-schools-reopen.html?referringSource=articleShare

4. Center for Disease Control and Prevention. Interim Guidance for Administrators of US K-12 Schools and Child Care Programs Plan, Prepare, and Respond to Coronavirus Disease 2019 (COVID-19). Published April 12, 2020. Accessed June, 3 2020 

https://www.cdc.gov/coronavirus/2019-ncov/community/schools-childcare/guidance-for-schools.html

5. Center for Disease Control and Prevention. National Center for Immunization and Respiratory Diseases (NCIRD), Division of Viral Diseases. Coronavirus Disease 2019 (COVID-19). Considerations for Schools. Published May 19, 2020. Accessed June 3, 2020. 

https://www.cdc.gov/coronavirus/2019-ncov/community/schols-childcare/schools.html

6. Centers for Disease Control and Prevention. Coronavirus Disease 2019 (COVID-19). K-12 Schools and child care program. Published June 3, 2020. Accessed June 17, 2020. 

https://www.cdc.gov/coronavirus/2019-ncov/community/schools-childcare/schools-faq.html?deliveryName=USCDC_2067-DM29945

7. AAP Council on School Health. Role of the School Nurse in Providing School Health Services. Pediatrics. Published June 2016. Accessed July 12, 2020. Accessed from 

https://pediatrics.aappublications.org/content/137/6/e20160852

8. Center for Disease Control and Prevention. Coronavirus disease 2019 (COVID-19). Interim considerations for K-12 school administrators for SARS-CoV-2 testing. Published June 30, 2020. Accessed July 12, 2020. 

https://www.cdc.gov/coronavirus/2019-ncov/community/schools-childcare/k-12-testing.html

9.Center for Disease Control and Prevention. For Parents: Multisystem Inflammatory Syndrome in Children (MIS-C) associated with COVID-19. Published May 20, 2020. Accessed June 10, 2020. 

https://www.cdc.gov/coronavirus/2019-ncov/daily-life-coping/children/mis-c.html

10. Hindson J. COVID-19: faecal-oral transmission?. 

. 2020:17(5):259. doi:10.1038/s41575-020-0295-7

11. WHO Water, Sanitation and Hygiene strategy 2018-2025. Geneva: World Health Organization; 2018 (WHO/CED/PHE/WSH/18.03). License: CC BY-NC-SA 3.0 IGO Published 2018. Accessed June 28, 2020. 

https://apps.who.int/iris/handle/10665/274273

Articles

As fall approaches, one of the biggest questions is: Can children return to school and be in classroom environments that assure health and well-being for all?

Safe return to school: A call to action

“Multisystem inflammatory syndrome (MIS-C) in children associated with COVID-19,”

 Drs Schulman and Krilov present a comprehensive review of MIS-C, including the recognition of symptoms and current treatment. They compared the MIS-C presentation to Kawasaki disease (KD). Today, every pediatric provider including pediatric nurse practitioners and pediatric nurses working in hospital or in outpatient settings must know the various ways children and adolescents may present with possible COVID-19 symptoms. Pediatric nurse practitioners must also identify those children or adolescents in their practices that are considered high risk for MIS-C. Drs Schulman and Krilov identify high risk children as those who present with a fever and severe abdominal pain, whose median age is between 10 and 11 years (age range 4 to 21 years) as well as children with African heritage.

Contact tracing essential for early identification of high risk and asymptomatic children

States that have implemented COVID-19 contact tracing strategies to identify individuals and families with a possible or known exposure to COVID-19, are recommended to include questions about children and adolescents living in the home, including their ages. Gathering the information is important but most important is relaying this information to their pediatric providers who care for the children. Best practice may be for contact tracers to ask the parents or caregivers the names and contact information of their pediatric providers and ask the parents to inform their providers of the possible or known exposure to COVID-19. For those parents without access to a pediatric provider, it is advisable for contact tracers to provide names of community-based pediatric providers who will see the child or adolescent if problems should arise. Follow up by the contact tracers to assure the children or adolescents have informed their pediatric providers is essential.

Frequent monitoring of the children and adolescents via telehealth visits should be considered as part of their pediatric provider plan of care. Because symptom presentation and management of children and adolescents differs from adults, documentation of telehealth visits may provide some insights for possible unrecognized early symptoms in children or adolescents, thus better informing early symptom recognition and decision making for treatment management if and when they begin to display symptoms of COVID-19 or MIS-C.

In addition, it is believed that some children and adolescents may be asymptomatic carriers of COVID-19. Thus, if contact tracers are testing the children and adolescents with known exposures, pediatric providers and researchers will have data about asymptomatic children and adolescents that can be analyzed to better inform pediatric providers about the COVID-19 and MIS-C in children and adolescents as we are immersed in this pandemic.

Can experiences in the immediate past predict a safer future?

Although everyone is grateful that, overall, children have had less hospitalizations for COVID-19, in the heart of a pediatric provider, even one child who suffers with severe symptoms is one too many. In the United States, children with MIS-C symptoms were first identified in New York as physicians, nurses, and first responders were making every effort to fight the virus raging among the adult population. As Drs. Schulman and Krilov discussed, the children were most likely asymptomatic for 4 or more weeks before the presentation of symptoms.

Today, as COVID-19 surges are occurring in many southern states and the west coast of the United States, will more children and adolescents be presenting with MIS-C in mid to late August in those states? The critical question is: Can this be prevented or at least recognized early and treated? Strategies to protect all children and in particular, those who are considered at highest risk, should be implemented.

Pediatric providers in the states with current surges may want to reach out to advise parents to:

1.) Keep their children and adolescents at home or send the children to a relative’s home who has not had an exposure;

2). Keep the person(s) who were exposed separated from the children;

3). Wear masks if they must go out of the home; and

4). Adhere to all of the Center for Disease Control guidance for social distancing, child and adolescent play activities and hand hygiene.

We can set a goal for a better immediate future by talking with parents and their children/adolescents by encouraging them to implement these safety precautions. We do not know if these strategies will be effective. However, parents, children, adolescents, and pediatric providers need to work together to successfully maintain the health of children and adolescents throughout this pandemic and these simple strategies may inform a safer future.

Every pediatric provider including pediatric nurse practitioners and pediatric nurses working in hospital or in outpatient settings must know the various ways children and adolescents may present with possible COVID-19 symptoms. They must also know which patients are at high risk of developing multisystem inflammatory syndrome in children (MIS-C).

 Identification of children at high-risk for MIS-C

What is our new norm for the delivery of primary health care to the pediatric, adolescent, and young adult populations? How do we help our patients and families remain healthy and safe in a world that challenges each individual, each family unit, and all communities and populations every day? Dr. Schuman begins the conversation in his article entitled, 

COVID-19: A battle plan for pediatricians

Dr. Schuman suggests that the COVID-19 pandemic will most likely lead to novel primary care practice models. He provides a strategy for a ‘battle plan’ at the end of his article.

Telehealth and telemedicine: The new norm?

Many primary care practices have been trying to ‘hold down the fort’ using telehealth and telemedicine visits. Telemedicine visits offer unique opportunities to ‘see’ and evaluate patients in real time. Telemedicine visits are ideally suited for addressing specific clinical problems, eg, dermatologic conditions, behavioral problems, weight management, asthma management, mild upper respiratory infections without an ill appearing child/adolescent, among others. Telemedicine visits have the potential to support meaningful changes to practice via innovative planning and designs that can provide unique peripherals for the evaluation of infants and young children. For example, infants and toddlers who are not due for immunization updates, may have their visits via telemedicine using ‘to be developed’ peripherals that evaluate the infant or toddler in similar ways that are done in office settings.

Recently, as limited reopenings have emerged, providers are scheduling in-person patient visits with significant modifications to office organization and patient flow. Assessing the parent or caregivers and child for possible exposure to COVID-19 prior to entering the office with the child is step 1 in assuring office safety precautions. Providing masks to all parents and children aged older than 2 years, if the parent has not come with a mask, is also a must. Waiting rooms will no longer be filled with parents and children and as Dr. Schuman has listed in his battle plan, the parking lot is now the waiting room.

Concerns for the health and well-being of children ‘march on’ in this COVID-19 pandemic

COVID-19 has confronted pediatric health care providers with overwhelming and unwelcoming feelings of ‘uncertainty’. We had become dependent on our knowledge base and the ability to search the literature to find answers to puzzling problems. We were comfortable in applying the principles of evidence-based practice and clinical practice guidelines to achieve the best possible health care outcomes for our patients. Suddenly, the literature was non-existent. Children were presenting critically ill in the United Kingdom and in the United States. Unexpectedly and with a high degree of ‘uncertainty’ in best care management strategies for these children, a new syndrome emerged: multisystem inflammatory syndrome in children (MIS-C). See Miranda Hester’s discussion entitled, 

CDC issues preliminary information on MIS-C

Uncertainty is uncomfortable and unwelcome in professions driven by scientific investigations and years of data analysis to solve complex health care problems. Solutions will emerge. I am confident of that. What is no longer uncertain is the prodigious need for nurse practitioners and all health care providers to maximize their efforts to help communities reverse the disparities directly related to the social determinants of health. If nothing else, COVID-19 makes the case for meaningful change in the delivery of health care to improve population health.

COVID-19 has wrought many changes, including how medical practices provide care and keep patients safe.

Delivery of primary care services amid the COVID-19 pandemic

 from March 16, 2020. The article provides the number of children in the Hubei region of China that presented with severe illnesses related to COVID-19 during the initial outbreak. Ms. Hester’s report is entitled: 

Severe COVID-19 cases are possible in children

publication, the news media queried medical experts in the United States who believed that children were primarily unaffected by COVID-19. The thinking was that children may be asymptomatic carriers. However, large scale testing of children in the United States has not been performed, thus, actual data for children was and is unknown. On April 30, 2020 our New York City Chapter of the National Association of Pediatric Nurse Practitioners held a meeting on COVID-19 in children based on the best available evidence. At that meeting, a member briefly discussed a newly identified presentation of children with symptoms similar to Kawasaki disease. The next day, 4 cases of a Kawasaki-like syndrome were reported in New York City. Nineteen days later, on May 18, 2020, 147 children in New York City, New York, and 15 children in New Jersey have confirmed cases of this newly named disorder, multisystem inflammatory syndrome in children (MIS-C).

 Many other states are now reporting similar cases of MIS-C in children. 

Was the first case of MIS-C unrecognized in China?

Multisystem Inflammatory Syndrome in Children was not reported in any children in the first systematic review published on April 22, 2020, examining 18 published articles on children positive for COVID-19 during the initial outbreak in Wuhan, China.

 However, the authors reported a case of 1 infant presenting with pneumonia, complicated by shock and kidney failure, but successfully treated in the intensive care unit. The infant also had vomiting, diarrhea, fever, and pneumonia, complicated by shock with metabolic acidosis and kidney failure that required intensive care and assisted ventilation. This infant survived. Was this the actual first case worldwide of MIS-C?

Castagnoli’s et al. systematic review included data from 1065 children with COVID-19 infection in China with 444 cases in children aged younger than 10 years, and 553 children aged between 10 and 19 years. Further, the authors reported that the children presented with symptoms similar to the presentations in adult populations eg, fever, dry cough, fatigue, sore throat, headache, loss of taste and smell, and/or shaking chills. Chest x-ray findings reported bronchial thickening, ground-glass opacities, as well as inflammatory lung lesions. No other cases similar to the critically ill infant were reported. Further, the authors suggested that preliminary data from children who tested positive for COVID-19 and remained asymptomatic, might be a source of viral transmission.

How can we make sense of data on MIS-C as well as asymptomatic cases in children? What are we missing? Which children are most susceptible to MIS-C? Is it preventable? What do we need to know to keep children safe as well as prevent transmission from asymptomatic children to high-risk populations? Which children are the high-risk population for contracting MIS-C? Can this ever-evolving vicious virus be tamed and eliminated? The hope of a vaccine provides a light at the end of the dark tunnel for health care professionals on the front lines. 

1. Russo M. Up to 147 NYC kids sickened by severe new COVID Syndrome; 15 cases confirmed in NJ. NBC New York. Published May 18, 2020. Accessed May 26, 2020. 

https://www.nbcnewyork.com/news/local/cdc-confirms-link-of-inflammatory-syndrome-in-children-to-covid-19-145-potential-cases-in-nyc/2421547/

2. Castagnoli R, Votto M, Licari A, et al. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in children and adolescents: a systematic review. 

. April 22, 2020. Epub ahead of print. doi: 10.1001/jamapediatrics.2020.1467

It was initially thought that children were primarily unaffected by COVID-19 and were asymptomatic carriers if they did have the disease. The rise of multisystem inflammatory syndrome in children (MIS-C) has radically changed this thinking.

Author | Donna Hallas, PhD, PPCNP-BC, CPNP, PMHS, FAANP, FAAN

Articles

Safe return to school: A call to action

Identification of children at high-risk for MIS-C

Delivery of primary care services amid the COVID-19 pandemic

Severe COVID-19 in children: Now termed MIS-C