The coronavirus 2019 (COVID-19) pandemic has created profound challenges for communities, families and individuals. While some of the challenges that characterized the initial phase of the pandemic have eased in their intensity, such as the need for quarantine and physical isolation, continued guidance on the effects of and response to the virus and the pandemic is needed.
One of the most critical lessons of the COVID-19 pandemic is the importance of in-person school. Remote learning exacerbated existing educational inequities, was detrimental to educational attainment and drastically worsened the growing mental health crisis among children and adolescents. The American Academy of Pediatrics (AAP) has called for safe in-person learning since its original COVID-19 school guidance released on June 24, 2020. Schools do not significantly increase community transmission, especially when guidance outlined by the World Health Organization (WHO), United Nations Children's Fund (UNICEF), and Centers for Disease Control and Prevention (CDC) is followed. 1,2 Transmission of SARS-CoV-2 in schools can still occur. The risk may be greater for individuals and families who are not vaccinated. However, schools and school-supported programs are fundamental to child and adolescent development and well-being. Schools provide our children and adolescents with academic instruction, social and emotional skills, safety, reliable nutrition, physical/occupational/speech therapy, mental health services, health services, oral health care and opportunities for physical activity, among other benefits.3 Families rely on schools to provide a safe, stimulating and enriching space for children to learn; appropriate supervision of children; opportunities for socialization; and universal support to cope with crisis and loss associated with the pandemic.
The AAP is committed to continuing to advocate for (1) using science to make local and state decisions to protect our communities from COVID-19; (2) combating disinformation and misinformation; (3) prioritizing in-person learning by continuing support for schools to implement recommended health and safety measures; and (4) creating policies that put the well-being of children and adolescents first, including children and youth who are immunocompromised or have a disability.
In order to safely keep children and adolescents in school, the following must happen:
All federal, state, and local policies must prioritize children and schools.
- Schools need adequate federal, state and local funding and resources so they can continue to implement universal infection control mitigation and safety measures through robust school nursing and health services. This is required to protect students and staff from COVID-19, common respiratory infections and any other potential future threats.
- School staff, including school nurses, teachers and administrators, should be supported as they continue to navigate in-person learning during the pandemic. They have had to work through new guidelines from various sources, funding issues, COVID-testing availability, school board changes and public backlash to provide our children and adolescents with the educational and socioemotional support they need to learn and thrive.
- The mental health and well-being of children and adolescents must be prioritized and funded.
School policies should protect students, school staff and teachers using science as a guide.
- COVID-19 vaccines and boosters as recommended by the CDC should be encouraged for students, staff and teachers. Vaccination has proven to lessen transmission, severity of disease and death. Adequate and timely COVID-19 vaccination resources for the whole school community must be available and accessible. School-located vaccine clinics are an important strategy to provide equitable COVID-19 vaccination. The CDC has information and recommendations available in its guide for planning school vaccination clinics.
- Ensure that school administration and medical staff (ie, school nurses and nurse aides) are given ample training and funding to be regularly updated on changes and to implement the latest recommendations regarding COVID-19 operational guidance in schools.
- School nurses and other school health services staff are responsible for the direct care of acutely ill and injured students, safety planning for students with chronic and life-threatening conditions, medication administration and skilled nursing services, screening, implementation of school wellness plans and many more critical functions that must continue. Support (including funding and additional staffing) and training for additional duties, such as on-site COVID-19 testing in schools for symptomatic students or screening with high-risk activities, must be provided.
- 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, including widely sharing district COVID-19-related policies.
School policies should follow mitigation measure strategies to prevent the spread of the virus.
- The AAP recommends COVID-19 vaccination for all eligible children and adolescents who do not have contraindications using a COVID-19 vaccine authorized for use for their age. Teachers and staff should also be vaccinated against COVID-19 as per CDC guidelines. Vaccination of all eligible individuals in schools is the single best strategy to protect students and staff from severe disease, hospitalization, and death and to maintain in-person learning.
- People should stay home when sick with new symptoms and isolate.
- People who are symptomatic or at high risk should be tested, following CDC guidelines. This will require providing adequate testing of students, teachers and staff.
- Although not required in many school districts, indoor masking is still beneficial. Individuals should especially consider masking their child (and family) with well-fitting masks, in the following situations:4
- If their child is currently ineligible for COVID-19 vaccine for medical reasons.
- If their child is immunocompromised and may not have a protective immune response to the COVID-19 vaccine or is at high risk for severe COVID-19 illness.
- If other members of the family are at higher risk of severe disease or are not immunized.
- If they live in a community with “high” COVID-19 transmission, as in-school transmission has been observed more often in school districts that did not enact mask requirements. 5,6
- In addition, some degree of school masking may be needed given the unique health circumstances of students who are immunocompromised or have disabilities in order to continue to receive in-person learning, particularly during times of high community transmission rates.
- School health staff should be provided with appropriate medical personal protective equipment (PPE) to use in health suites. This PPE should include N95 masks, surgical masks, gloves, disposable gowns and face shields or other eye protection. School health staff should be aware of CDC guidance on infection control measures.
- Improve ventilation in school buildings.7,8,9,10
- Ventilation helps reduce exposure to SARS-CoV-2 and other respiratory pathogens as it helps dilute the viral load by reducing virus-containing aerosols in the air.11 The allocation of funds by the US Department of Education to facilitate resources to improve ventilation in US schools acknowledges the importance of proper ventilation in preventing the spread of COVID-19 and improving indoor air quality overall.
- In addition to increasing the flow of clean outdoor air when conditions permit, other simple measures to improve ventilation, such as properly placed fans, use of portable HEPA units (properly sized for the room) or creation of directional airflow, can help improve indoor air quality. 12,13
- Certain previous strategies are not recommended (eg, the use of ozone-generating devices, the use of plastic or plexiglass dividers or desk shields). These are not helpful in reducing the spread of the virus and may serve as fomites.
- Provide adequate and consistent opportunities for hand washing and appropriate school cleaning techniques.
The AAP strongly advocates for the re-emphasis of attendance.
The best way to reduce absenteeism is by closely monitoring attendance and acting quickly once a pattern is noticed. Daily school attendance should be monitored for all students, including students participating in in-person and distance learning. Schools should use multi-tiered strategies to proactively support student attendance for all students. Additionally, schools should implement strategies to identify and differentiate interventions to support those at higher risk for absenteeism. Local data should be used to define priority groups whose attendance has been most deeply impacted during the pandemic. Schools are encouraged to create an attendance action plan with a central emphasis on family engagement throughout any school year.14
In an evaluation of Connecticut's attendance data from school year 2020-21, rates of chronic absenteeism were highest among predominantly remote students compared with students who were primarily in person; that gap was most pronounced among elementary and middle school students. Chronic absence was more prevalent among Connecticut students who received free or reduced-price lunch, students who were Black or Hispanic, students who were male and students who identified as English learners or having disabilities.15 National pre-pandemic chronic absenteeism data mirror several of these demographic trends.16
The importance of daily attendance, directly linked to long-term academic success and good health, cannot be overstated. Pediatricians should address school attendance in their office-based practices and communities and advocate on a system and policy level to reduce chronic absenteeism. Resources are available from the AAP and Attendance Works to guide pediatricians in these tiered interventions.
The AAP strongly recommends that school districts promote racial/ethnic and social justice by promoting the well-being of all children in any school COVID-19 plan, with a specific focus on ensuring equitable access to educational support for children living in under-resourced communities and children and youth with disabilities.
- Schools can play a critical role in addressing racial and social inequity.
- Schools should monitor and support the attendance of all students daily in both in-person and virtual settings.
- Special considerations and accommodations to account for the diversity of youth should be made, especially for populations facing inequities, including those who are medically fragile or complex, have developmental challenges or have disabilities. Children and youth with disabilities should continue to receive “reasonable modifications to ensure that students with disabilities have meaningful access to in-person schooling without incurring an elevated risk of hospitalization or death due to COVID-19” under Title II of the Americans with Disabilities Act and Section 504 of the Rehabilitation Act.17
- In addition, “based on the unique needs of the child, the team (school officials and the child’s parents), could determine that some degree of masking is necessary to ensure a specific child can receive a free appropriate public education (FAPE) in the least restrictive environment (LRE)” under the Individuals with Disabilities Education Act.18
- School policies should be guided by supporting the overall health and well-being of all children, adolescents, their families and their communities in addition to creating 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, when needed, based on the languages spoken in the community, to avoid marginalization of parents/guardians of limited English proficiency or who do not speak English.
Visit the CDC COVID-19 Prevention Strategies for additional information on mitigation measures.
In the following sections, some general principles are reviewed that policy makers and school administrators should consider as they plan for school as well as for before- and after-school programs. Several other documents produced by the CDC, the US Department of Education, the National Association of School Nurses and the National Academy of Sciences, Engineering, and Medicine can be referenced as well. For all of these, engagement of the entire school community, including families, teachers, and staff, regarding these measures should be a priority.
Special Considerations for School Health During the COVID-19 Pandemic
Behavioral Health/Emotional Support for Children and Adolescents
We must take the lessons learned from the pandemic and make them into actionable policy. The COVID-19 pandemic created profound challenges for communities, families, and individuals, leading to a range of emotional and behavioral responses. The loss of and grief over caregivers and trusted adults, the prolonged uncertainty and duration of the crisis, the rapidly changing and conflicting messages and the isolation as a result of remote schooling and the need for quarantine has led to a range of emotional and behavioral responses from children and adolescents. Populations with a higher baseline risk, such as historically under-resourced communities, children and youth with developmental disabilities and other special health care needs and children with pre-existing depression, anxiety and other mental health conditions, are especially vulnerable to these effects. Bereavement has a significant impact on the short- and long-term adjustment of children, their developmental trajectory, academic learning, psychosocial functioning and emotional adjustment and behavior. Students experiencing significant personal losses can be referred to school and community-based bereavement support programs, centers, and camps as well as to their pediatrician or other pediatric health care provider. Students with additional mental health concerns should be referred to school mental health professionals.
Schools are a vital resource to continue to address and provide resources for a wide range of mental health needs of children and staff. Schools must adopt an approach to provide mental health support during the school day. This may include improving and scaling up programs that increase safe and supportive environments within schools through school connectedness and youth connectedness as well as providing adequate staff training to address the socioemotional needs of students and staff in the school. Schools should consider including a trauma-informed lens and approach to all mental, emotional and behavioral health concerns. In addition, schools will have to provide sufficient counseling and therapy opportunities for students in need and strengthen connections with local mental health providers inside the school building, including school-based health centers. All of this will need to be provided at low or no cost to students and their families, which will require additional federal and local funding to ensure adequate programming for students and staff.
Suicide is the second leading cause of death among adolescents or youth 10 to 24 years of age in the United States. Schools should develop mechanisms to evaluate all students, whenever concerns about a risk of suicide are voiced by educators or family members. Schools should also establish policies including referral mechanisms for students believed to be in need of in-person evaluation even before they resume in-person instruction.
There has been an educational impact on children and adolescents as a result of the COVID-19 pandemic. Schools need to incorporate academic accommodations to support all students who are struggling and testing should be used to evaluate educational needs. The AAP discourages the use of testing to determine school funding. School should not be a source of further distress for children and adolescents.
Mental Health of Staff
The personal impact on educators and other school staff should be recognized. In the same way that students need ongoing support to process the information they are being taught, educators cannot be expected to be successful at teaching and supporting children without having their mental health needs supported. The strain on educators as they have been asked to teach differently while they support their own needs and those of their families has been significant. Additional challenges with staff shortages, illness and safety fears for themselves and their families, changing learning modalities and prolonged duration of the crisis continues to present additional challenges and further impact teachers and school staff. Resources such as Employee Assistance Programs and other means to provide support and mental health services should be prioritized. The individual needs and concerns of school professionals should be addressed with accommodations made as needed.
Students with Disabilities
The COVID-19 pandemic has impacted the delivery of special education services for students with disabilities. It has resulted in lost instructional time and related services or less effective delivery methods in other cases. Students with disabilities have also been impacted by the pandemic in similar ways as other students. The needs of children and adolescents with disabilities may have changed from what they were before the pandemic. As such, it is important for schools to consider frequent reviews of what those needs are and how they are reflected in each child’s Individualized Education Program (IEP). There is a continued need to advocate for adequate funding to support special education services. Many school districts require adequate instructional effort before determining eligibility for special education services. However, virtual instruction or lack of instruction should not be reasons to avoid starting services such as response-to-intervention (RTI) services, even if a final eligibility determination is delayed.
Each student’s IEP should be reviewed with the parent/guardian/adolescent yearly (or more frequently if indicated). All recommendations in the IEP should be provided for the individual child no matter which school option is chosen (in person, blended, or remote).
Some students with disabilities will need extra protection (masking by adults and students around them) even if the rest of the school has relaxed standards.19 In addition, teachers and staff may need to use clear paneled masks to adequately serve students who are deaf or hard of hearing, students receiving speech/language services, young students in early education programs and English language learners.
On-site School-Based Health Services
On-site school health services, including school-based health centers, should be supported if available, to complement the pediatric medical home and to provide pediatric acute, chronic, preventive and behavioral health care. Collaboration with school nurses is essential, and school districts should involve school health services staff and consider collaborative strategies that address and prioritize immunizations and other needed health services for students, including behavioral health, vision screening, hearing, dental and reproductive health services. Plans should include required outreach to connect students to on-site services regardless of remote or in-person learning mode. School-based health centers (SBHCs) may want to serve as COVID-19 immunization sites in addition to providing childhood and adolescent vaccinations, for students and staff at their schools and in the surrounding communities. Public health agencies can provide support and technical assistance for SBHCs to assist them in establishing immunization clinics for all vaccines, including COVID-19.
Pediatricians should work with schools and local public health authorities to promote childhood vaccination messaging throughout the school year. It is vital that all children receive recommended vaccinations on time and get caught up if they are behind as a result of the pandemic and vaccine misinformation. The capacity of the health care system to support increased demand for vaccinations should be addressed through a multifaceted, collaborative, and coordinated approach among all child-serving agencies including schools.
Existing school immunization requirements should be discussed with the student and parent community and maintained. In addition, although influenza vaccination is generally not required for school attendance, it should be highly encouraged for all students and staff. The symptoms of influenza and SARS-CoV-2 infection are similar and taking steps to prevent influenza will decrease the incidence of disease in schools and the related lost educational time and resources needed to handle such situations by school personnel and families. School districts may consider requiring influenza vaccination for all staff members.
Schools should collaborate with state and local public health agencies to ensure that teachers and staff have access to the COVID-19 vaccine and that any hesitancy is addressed as recommended by the Advisory Committee on Immunization Practices (ACIP) of the CDC. Pediatricians should work with families, schools, and public health authorities to promote receipt of the COVID-19 vaccine and address hesitancy and misinformation.
In order to vaccinate as many school staff, students, and community members as possible, school-located vaccination clinics (partnered or through SBHCs) should be a priority for school districts. Schools are important parts of neighborhoods and communities and serve as locations for community members after school hours and on weekends. These clinics should be conducted in collaboration with students’ medical homes.
Vision screening practices should continue in schools. Vision screening serves to identify children who may otherwise have no outward symptoms of blurred vision or subtle ocular abnormalities that, if untreated, may lead to permanent vision loss or impaired academic performance in school. Furthermore, there is some evidence that myopia has increased among children during the pandemic. 20,21
Safe hearing screening practices should continue in schools. School screening programs for hearing are critical in identifying children who have hearing loss as soon as possible so that reversible causes can be treated and hearing restored. Children with permanent or progressive hearing loss will be habilitated with hearing aids to prevent impaired academic performance in the future. Personal prevention practices and environmental cleaning and disinfection are important principles to follow during hearing screening, along with any additional guidelines from local health authorities.
Oral health programs should continue in schools. During the COVID-19 pandemic, risk factors for dental decay increased as access to dental services declined dramatically. School-based oral health programs are designed to address barriers to access for children at high risk to prevent dental decay and improve overall health and academic success. Using a preventive frame, these programs can provide oral health education, promotion of healthy school nutrition, oral health screening and dental sealants in school buildings through drop-in services, including mobile vans operating on school grounds, through SBHCs and/or in the community but school linked.22 School districts and school-based oral health providers should collaborate with state and local public health agencies to promote the safe continuation or restart of school-based oral health programs. School-based programs should ensure adherence to CDC guidance for the operation of dental facilities and school sealant programs during the COVID-19 pandemic.
Children with Chronic Illness
Certain children with chronic illness may be at risk for hospitalization and complications with SARS-CoV-2. These youth and their families should work closely with their pediatrician and school staff using a shared decision-making approach regarding options for return to school, whether in person, blended, home schooling, or remote.
According to the US Department of Agriculture, in 2020, 38.3 million people, including 12 million children, lived in a household with food insecurity. We also know that disparities with food insecurity exist, with Black and Hispanic adults being twice as likely as white adults to report that their households did not get enough to eat.23 School planning must consider the many children and adolescents who experience food insecurity already (especially at-risk populations and those living in poverty) and those who will have limited access to routine meals through the school district in the event of school closure or if a child is ill. The short- and long-term effects of food insecurity in children and adolescents are profound. Schools can partner with community resources including federal and state food programs to mitigate the effects of food insecurity on children and families.
Like food insecurity, housing insecurity is a significant and sometimes overlooked issue that affects many families and will impact children’s ability to return and re-engage with school. With pandemic-associated job losses, there have been significant numbers of families with children who have been evicted or will soon be evicted from their homes. According to the US Census Bureau data, as of September 2021, 11.9 million adults living in rental housing are not caught up on rent; the percentage is higher for Black, Hispanic and Asian renters. For renters with children, 1 in 5 are not caught up with last month’s rent.24 Housing insecurity impacts a child's education directly through missed school days and through transferring to a new school, which is associated with a 4 times higher risk of chronic absenteeism, lower grades and test scores and increased risk of dropping out of school. Housing insecurity also impacts education indirectly by impacting a child's overall physical and mental health, which can have negative consequences for educational achievement. Children who experience homelessness are at increased risk for malnutrition, asthma, obesity, and dental, vision, emotional, behavioral and developmental problems. In addition, the increased toxic stress children experience when they live in unstable housing situations can contribute to anxiety and other mental health conditions that interfere with a child’s education. The interconnectedness of employment, housing, health and education and the disproportionate impact this has had on communities of color because of structural racism must be considered as children return to school. Schools are encouraged to partner with community agencies to address the effects of housing insecurity and mitigate the impact this will have on the education of children.
The digital divide has been a known disparity for decades, contributing to the “homework gap”—the gap between school-aged children who have access to high-speed internet and adequate devices at home and those who do not. According to a Pew research study in 2015, 35% of lower-income households with school-aged children did not have a broadband internet connection at home. That same study revealed that 1 in 5 teenagers are not able to complete school work at home because of a lack of a computer or internet connection. This technological homework gap disproportionately affects Black families living in poverty.25 With the transition to virtual learning during the pandemic, this divide was highlighted as families struggled to adapt to school from home. In April 2020, 59% of parents with lower incomes who had children in schools that were remote because of the pandemic said their children would likely face at least 1 of 3 digital obstacles to their schooling, such as a lack of reliable internet at home, no computer at home, or needing to use a smartphone to complete schoolwork. Gains have been made over the past two years with creative local and state solutions working toward providing improved access to both technology devices and internet connections for students, but a significant gap still exists, particularly for students living in poverty or in temporary housing. This digital divide is a critical component to be addressed in schools even as children return to in-person learning as they navigate the increasing digital learning environment, academic recovery, and extended home learning materials. Access to both reliable high-speed internet and adequate devices beyond a smart phone are critical to promote equity and support academic success. Long-term sustainable funding is needed to support school districts in providing universal internet access and technology for all students; this should remain a priority after the pandemic.
The AAP Interim Guidance on Return to Sports helps pediatricians inform families on how best to ensure safety during sports and physical activity participation. Preparticipation evaluations should be conducted in alignment with the AAP Preparticipation Physical Evaluation Monograph, 5th ed, and state and local guidance, with particular attention to considerations for students who have a history of COVID-19. In addition, the CDC provides recommendations on screening and testing of students and adults participating in school sports and other extracurricular activities based on the activity’s risk for COVID transmission and the level of community transmission.
Interim Guidance Disclaimer: The COVID-19 clinical interim guidance provided here has been updated based on current evidence and information available at the time of publishing. Guidance will be regularly reviewed with regards to the evolving nature of the pandemic and emerging evidence. All interim guidance will be presumed to expire on December 31, 2022 unless otherwise specified.
American Academy of Pediatrics