The American Academy of Pediatrics (AAP) strongly endorses the uninterrupted care of children during the severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) pandemic in a manner that is safe for pediatricians, office staff, children, and families. The AAP recommends that all individuals older than 2 years wear a face mask when outside of the home. The Centers for Disease Control and Prevention (CDC) has provided recommendations for health care personnel and others in health care settings.
Consistent and effective infection prevention and control (IPC) practices need to be employed (including the appropriate use of personal protective equipment [PPE]) to mitigate the risk of infection for all who work or receive care in ambulatory settings. Although the evidence base continues to evolve, this resource offers guidance for pediatric care in ambulatory settings (eg, offices, urgent care centers, school-based or school-linked clinics, and homes).
Evidence suggests that a majority of the transmission of SARS-CoV-2 occurs from an infected individual, whether symptomatic or not, to another individual in close proximity, whether via aerosols or droplets. In high-risk settings, including health care settings as well as close contact between individuals in areas where higher levels of positive tests for the virus exist, masks should still be used universally.
- Although each practice’s standardized approach must take into account individual practice protocols, staffing, and local and regional epidemiology, the guiding principles for ALL practices should include use of appropriate PPE, including masks in patient-care settings, hand hygiene, disinfection of equipment and physical facilities, and efforts to promote optimal physical distancing given the types of clinical interactions and procedures.
- Each patient care facility, regardless of size, should have written IPC protocols specific to the setting, patient population served, and types of procedures provided. These protocols must, at a minimum, be consistent with federal, state, and/or local public health guidelines and, when applicable, health care system IPC policy.
- Staff at increased risk for severe illness manifestations related to coronavirus disease 2019 (COVID-19) (or those who have family members in their household who are at risk) should be offered the most protective level of PPE available and may require further mitigation.
- Staff should be trained on the expected use of PPE including face coverings, standard procedure masks, N95 respirators, protective eye wear (eg, goggles, face shields), gloves, and gowns for various care scenarios, taking local public health mandates into account. Routine patient contact should include masks, and eye protection when contact with secretions is likely, while contact in high-risk settings requires properly fitted N95 respirators and eye protection. Individual healthcare workers may have circumstances where use of higher level of PPE may be appropriate not limited to isolation/quarantine periods, and use of higher levels of PPE should be supported in these circumstances.
- If staff are permitted to return to work before meeting all conventional return to work criteria, they should wear a respirator or well-fitting facemask continuously even when they are in non-patient care areas such as breakrooms.
PPE and Risk Mitigation Strategies
- PPE Supply: Availability of masks and N95 respirators is generally adequate at this time. In the event of a shortage, the CDC offers guidance on how to optimize supply.
- Risk Mitigation: In addition to PPE, other IPC measures, including equipment and facility disinfection and engineering controls such as physical barriers (eg, sneeze/cough guards), defined routes for patient flow, increased ventilation and rate of air circulation, and use of high-efficiency particulate air (HEPA) filters, are also important in developing ambulatory practice IPC protocols. See information on protecting workers from the Occupational Safety and Health Administration (OSHA). Hospitals and other health care institutions that use N95 respirators are required by OSHA to implement a Respiratory Protection Program (also see the CDC Toolkit).
- Return to Work after COVID-19 Infection: Due to concerns about increased transmissibility of the SARS-CoV-2 Omicron variant, the CDC updated guidance to enhance protection for staff, patients, and visitors and to address concerns about potential impacts on the healthcare system given a surge of SARS-CoV-2 infections.
While vaccination has been shown to protect against severe COVID-19 disease, hospitalization and death, vaccinated individuals can still experience infections and can spread the SARS-CoV-2 virus to others. For this reason, the recommendations for PPE use as both source control and individual protection are the same for all individuals, regardless of their vaccination status.
Aerosol-Generating Procedures (AGPs)
According to the CDC, these procedures are those that produce smaller respiratory droplets at higher concentrations, thereby increasing the risk for transmission to people in proximity to the patient. AGPs include procedures that instrument the larynx or trachea (bronchoscopy, laryngoscopy, endotracheal intubation, insertion of a laryngeal mask airway) and those that assist ventilation (noninvasive ventilation including bag-mask, bilevel positive airway pressure [BIPAP] and continuous positive airway pressure [CPAP], cardiopulmonary resuscitation). Patients with a tracheostomy are believed to be high risk for aerosolization of secretions. Sputum induction/cough assist procedures are also considered AGPs. While use of a nebulizer for medication administration and use of high flow O2 are AGPs, it is still uncertain whether aerosols generated with these procedures are infectious. Higher levels of PPE (gloves, gowns, goggles or face shields, and masks/respirators) are necessary for the protection of those treating patients more likely to aerosolize respiratory secretions and/or when performing an AGP. The CDC advises that NIOSH-approved N95 or equivalent or higher-level respirators should be used for all aerosol-generating procedures. When performing procedures that could produce expelled droplets of respiratory or oral secretions, tears, or a gag or cough (such as immunizations, injections, oral examinations, or fluoride varnish applications), health care personnel may consider increasing their level of PPE.
These pandemic infection prevention and control recommendations may represent a substantial increase in practice expense for health care professionals working in ambulatory care settings. See the 99072 Payer Letter to assist members in appealing denials.
PPE Use to Mitigate Risk to Patients and their Family Members
- Hand sanitizer should be available and used by all patients/families entering the office.
- All patients ≥2 years of age and family members who enter a health care facility should wear a clean well-fitting face mask and practice physical distancing when possible. (See this CDC information on face masks for more information.)
- Offices should have a protocol for addressing refusal to wear a mask in the facility.
- Special considerations may exist for children and youth with special health care needs (CYSHCN) with respect to appropriate use of PPE.
- Project Firstline
- COVID-19 Vaccine: What Pediatricians Can Do Now
- Infection Control Guidance for Healthcare Professionals about Coronavirus (CDC)
Information for Families from HealthyChildren.org
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