COVID-19 Planning Considerations: Guidance for School Re-entry

American Academy of Pediatrics Interim Clinical Guidance

To view the full Interim Guidance online, click here.

The purpose of this guidance revision is to continue to support communities, local leadership in education and public health, and pediatricians collaborating with schools in creating policies for school re-entry during the coronavirus disease 2019 (COVID-19) pandemic that foster the overall health of children, adolescents, educators, staff, and communities and are based on available evidence. Along with our colleagues in the field of education, the American Academy of Pediatrics (AAP) strongly advocates for additional federal assistance to schools throughout the United States, with no restrictions regarding their plans for in-person versus virtual learning. Regardless, in places in the United States with high levels of community transmission of severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2), the virus that causes COVID-19, where in-person learning is not possible, these schools will also need more assistance, not less, to support the additional staffing needs, alternative learning sites, hybrid educational models, and child care.

Schools and school-supported programs are fundamental to child and adolescent development and well- being and provide our children and adolescents with academic instruction, either in person or virtually; social and emotional skills; safety; reliable nutrition; physical/speech therapy and mental health services; and opportunities for physical activity, among other benefits. Schools also serve as critical centers in communities by supporting adult-focused activities (such as job training, neighborhood meetings, and parenting classes) as well as ensuring safe places for children and adolescents to be while parents or guardians are working, which in turn supports the local economy.

Beyond supporting the educational development of children and adolescents, schools play a critical role in addressing racial and social inequity. As such, it is critical to reflect on the differential impact the COVID-19 pandemic and the associated school closures have had on different racial and ethnic groups and vulnerable populations. The AAP condemns the persistent racial and social inequities that exist within the US educational system. The disparities in school funding, quality of school facilities, educational staffing, and resources for enriching curriculum between schools have been exacerbated by the pandemic. Families rely on schools to provide child care; a safe, stimulating space for children to learn; opportunities for socialization; and access to school-based mental, physical, and nutritional health services. Without adequate support for families to access these services, disparities will likely worsen, especially for children who are English language learners, children with disabilities, children living in poverty, and children of African American/Black, Latinx/Hispanic, and Native American/Alaska Native origin.1,2

For children and adolescents in virtual learning models, educational disparities may widen further. According to the Pew Research Center, 1 in 5 teenagers are not able to complete schoolwork at home because of lack of a computer or internet connection.3 This technological “homework gap” disproportionately affects Black, Hispanic, and low-income families.3

The AAP strongly recommends that school districts promote racial/ethnic and social justice by promoting the well-being of all children in any school-reopening plan, particularly children living in marginalized communities. To address these disparities, federal, state, and local governments should allocate resources to provide equitable access to educational supports. These recommendations are provided, acknowledging that our understanding of the COVID-19 pandemic is changing rapidly.

Any school re-entry policies should consider the following key principles:

  • To be able to open schools safely, it is vitally important that communities take all necessary measures to limit the spread of the SARS-CoV-2.
  • School policies must be flexible and nimble in responding to new information, and administrators must be willing to refine approaches when specific policies are not working.
  • Schools must take a multi-pronged, layered approach to protect students, teachers, and staff. By using different approaches, these layers of protection will make in-person learning safe and possible.
  • It is critically important to develop strategies that can be revised and adapted depending on the level of viral transmission and test positivity rate throughout the community and in the schools, recognizing the differences between school districts, including urban, suburban, and rural districts.
  • School districts must be in close communication and coordinate with state and/or local public health authorities, school nurses, local pediatric practitioners, and other medical experts.
  • School re-entry policies should be practical, feasible, and appropriate for child and adolescent’s developmental stage and address teacher and staff safety.
  • Special considerations and accommodations to account for the diversity of youth should be made, especially for vulnerable populations, including those who are medically fragile or complex, live in poverty, have developmental challenges, or have disabilities, with the goal of safe return to school. These youth and their families should work closely with their pediatrician using a shared decision- making approach regarding return to school.
  • Pediatricians, families, and schools should partner together to collaboratively identify and develop accommodations when needed for any child or adolescent with unique medical needs.
    • Children and adolescents who need customized considerations should not be automatically excluded from school unless required in order to adhere to local public health mandates or because their unique medical needs would put them at increased risk for contracting COVID- 19 during current conditions in their community.
  • School policies should be guided by supporting the overall health and well-being of all children, adolescents, their families, and their communities but should also look to create safe working environments for educators and school staff. This focus on overall health and well-being includes addressing the behavioral/mental health needs of students and staff.
  • These policies should be consistently communicated in languages other than English, if needed, based on the languages spoken in the community, to avoid marginalization of parents/guardians who are of limited English proficiency or do not speak English at all.
  • Federal, state, and local funding should be provided for all schools so they can provide all the safety measures required for students and staff. Funding to support virtual learning and provide needed resources must be available for communities, schools, and children facing limitations implementing these learning modalities in their home (eg, socioeconomic disadvantages) or in the event of school re-closure because of resurgence of SARS-CoV-2 in the community or a school outbreak.

With the above principles in mind, the AAP strongly advocates that all policy considerations for the coming school year should start with a goal of having students physically present in school. Unfortunately, in many parts of the United States, there is currently uncontrolled spread of SARS-CoV-2. Although the AAP strongly advocates for in-person learning for the coming school year, the current widespread circulation of the virus will not permit in-person learning to be safely accomplished in many jurisdictions. The importance of in-person learning is well-documented, and there is already evidence of the negative impacts on children because of school closures in the spring of 2020. Lengthy time away from school and associated interruption of supportive services often results in social isolation, making it difficult for schools to identify and address important learning deficits as well as child and adolescent physical or sexual abuse, substance use, depression, and suicidal ideation. This, in turn, places children and adolescents at considerable risk of morbidity and, in some cases, mortality. Beyond the educational impact and social impact of school closures, there has been substantial impact on food security and physical activity for children and families. The disproportionate impact this has had on Black, Latinx, and Native American/Alaskan Native children and adolescents must also be recognized.

Policy makers and school administrators must also consider the mounting evidence regarding COVID-19 in children and adolescents, including the role they may play in transmission of the infection. SARS-CoV-2 appears to behave differently in children and adolescents than other common respiratory viruses, such as influenza, on which much of the current guidance regarding school closures is based. Although children and adolescents play a major role in amplifying influenza outbreaks, to date, this does not appear to be the case with SARS-CoV-2. Although many questions remain, the preponderance of evidence indicates that children and adolescents can become infected and are less likely to be symptomatic and less likely to have severe disease resulting from SARS-CoV-2 infection.4 We continue to learn more about the role children play in transmission of SARS-CoV-2. At present, it appears that children younger than 10 years may be less likely to become infected and less likely to spread infection to others, although further studies are needed.5 More recent data suggest children older than 10 years may spread SARS-CoV-2 as efficiently as adults, and this information should be part of the considerations taken in determining how to safely and effectively open schools. Additional in-depth studies are needed to truly understand the infectivity and transmissibility of this virus in anyone younger than 18 years, including children and adolescents with disabilities and medical complexities. Policies to mitigate the spread of COVID-19 within schools must be balanced with the previously noted known harms to children, adolescents, families, and the community that come with keeping children at home.

Finally, policy makers and school administrators should acknowledge that COVID-19 policies are intended to mitigate, not eliminate, risk. No single action or set of actions will completely eliminate the risk of SARS-CoV-2 transmission, but implementation of several coordinated interventions can greatly reduce that risk. For example, where physical distance cannot be maintained, students (older than 2 years) and staff should wear cloth face coverings (unless medical or developmental conditions prohibit use). In the following sections, some general principles are reviewed that policy makers and school administrators should consider as they safely plan for the coming school year. For all of these, engagement of the entire school community, including teachers and staff, regarding these measures should begin early, ideally at least several weeks before the start of the school year.

Since this guidance was first released, there have been several other documents released by the Centers for Disease Control and Prevention (CDC), National Association of School Nurses, and the National Academy of Sciences, Engineering, and Medicine. All these documents are consistent regarding the importance of considering the degree to which SARS-CoV-2 is circulating in a community in making school re-opening policies. In many places in the United States at the present time, opening schools to in-person learning for all students is likely not feasible because of widespread community transmission and high levels of positivity in testing. Even in these communities, though, in-person learning should still be the goal and may be feasible as the epidemiology improves. Countries that have been able to successfully open schools have had low rates of community SARS-CoV-2 circulation. This guideline is intended to augment, not replace, guidance from the CDC and others and should be used in concert with other guidance. Ultimately, the decision to re-open schools to in-person learning should be based on the guidance of local and state public health authorities and school administrators.