While most schools and universities are currently closed, many states in the U.S. will make their own decisions about whether schools will return for the rest of the academic year. In order to help schools open safely, the American Academy of Pediatrics (AAP) has issued a set of guidelines for best practices.

The authors of the new report note that safety should come first and that schools should partner closely with local health departments to assess risks, which can differ greatly from county to county.

“From a health perspective, the health of kids and the health of staff has to be thought through before schools reopen,” Dr. Nathaniel Beers, one of the authors of the guidelines and a pediatrician at Children’s National Hospital in Washington, D.C.

The decision to open schools again is not an easy one to make. On the one hand, there are obvious risks to public health. On the other hand, keeping schools closed for too long deprives children of their education, despite commendable efforts to continue schooling online.

What’s more, many children from low-income families rely on free meals served at schools. Others require special education services like speech therapy and occupational therapy.

“Teachers may live in areas without good Wi-Fi. A lot of kids don’t have access to the technology they need. There have been a lot of problems with consistency and equity, and with who can get a meaningful learning experience. Schools have been creative—bus drivers might drive their routes to deliver meals to kids, or to provide a Wi-Fi hot spot from a router in the bus,” Lily Eskelsen Garcia, president of the National Education Association (NEA), said in a statement.

What are the risks faced by children?

The worst outcomes of COVID-19 are experienced by those older than 65 or with underlying chronic diseases — most people are well aware of this. But what about children?

Initially, scientists thought that children were less likely to catch the disease in the first place. For instance, a study that followed 1,099 patients with COVID-19 from 552 hospitals in 30 Chinese provinces found very few infections among children — just 0.9% of confirmed cases were under the age of nine, while only 1.2% were between 10 and 19 years old. Of the nine children with COVID-19 in the study, just one developed severe symptoms.

In another recent analysis, researchers in the US and China analyzed more than 72,000 confirmed cases from China, finding that children under the age of 10 accounted for under 1% of all infections. There were 1,023 deaths in the sampled population, but not a single child was among them.

The real rate of infection among children might be much higher, though.

It seems like children may be just as likely to catch the novel coronavirus as any other age group — it’s just that they rarely develop symptoms.

Justin Lessler, an infectious disease epidemiologist at Johns Hopkins Bloomberg School of Public Health, co-led a study with colleagues at the Harbin Institute of Technology in Shenzhen and the Shenzhen Center for Disease Control and Prevention in which they monitored 391 COVID-19 patients and 1,286 people who had come in contact with these patients.

When these contacts were tested, the researchers found that children aged 9 and younger were just as likely as other age groups to get infected (7-8% of the time).

Most of the children did not show any symptoms at all but they still carried viral loads that can infect other people.

What’s more, when they do feel sick and exhibit symptoms, some children with COVID-19 risk factors can develop some of the worst outcomes.

A new study published this week followed 48 American and Canadian children and young adults (from newborns to 21 years) who were diagnosed with COVID-19 and admitted to pediatric intensive care units. The researchers found that 80% of them had at least one chronic underlying condition (obesity, diabetes, chronic lung disease, and immune suppression). Unfortunately, two of the patients died while receiving care while others required ventilatory support.

“The idea that COVID-19 is sparing of young people is just false,” said study co-author Lawrence C. Kleinman, professor and vice-chair for academic development at Rutgers Robert Wood Johnson Medical School.

“While children are more likely to get very sick if they have other chronic conditions, including obesity, it is important to note that children without chronic illness are also at risk. Parents need to continue to take the virus seriously.”

These studies show that children and teens rarely develop the worst outcomes of COVID-19 that are fatal for older adults, but they still can pass the virus to their households and, in some rare cases, can get very sick and die.

When to open schools

According to the AAP, schools can consider reopening as long as they address the following issues:

• The availability of testing and contact tracing.
• Implementing infection control measures, such as disinfecting classrooms and surfaces, screening children and staff, use of masks, appropriate social distancing, limiting interactions between children and staff, and testing for infection when appropriate.
• The availability of supplies for disinfecting and testing.
• How plans for opening will differ by grade level
• A plan for possible intermittent school closings.
• Creating options for a phased reopening, perhaps with reduced school hours, to allow local health officials to monitor community infection rates.
• Making plans for children with high-risk medical conditions who might not be able to return to school safely.
• Considering plans for sports teams and events, as well as other extracurricular activities.

These considerations are echoed by teachers’ unions in the UK, such as the National Association of Headteachers (NAHT) and the National Education Union (NEU), who have called for “clear, scientific published evidence” that schools are safe to re-open.

In a joint statement, the UK school teachers said that “there should be no increase in pupil numbers until a national test, track and trace scheme has been fully rolled out.”

Other countries have already reopened their schools, including Norway, Japan, Denmark, China, and Taiwan. However, children will have to adjust to a new reality. In these countries, staff members are taking students’ temperatures at the door. Some schools have closed playgrounds, and are spacing desks in classrooms a safe six feet apart.

Germany announced that it will allow students back to school in the coming weeks, but with class sizes cut in half. Teachers will have to wear masks and students are told to dress more warmly as windows and doors will be kept open to increase air circulation.

Of course, all of this costs money and with many U.S. public schools already running on a tight budget pre-pandemic, many of these measures might be unfeasible for some districts.

“Tax revenue is going to decrease dramatically. Not only will we not have money to reduce class sizes, we may have huge layoffs,” Eskelsen Garcia said in a statement.

“Kids will have faced months of fear and uncertainty and lived through trauma, but school nurses and school psychologists will likely be laid off,” Eskelsen Garcia said. “And we need more custodians to disinfect schools and they need training on disinfecting for coronavirus. If we don’t have what we need this time, someone could actually die,” she said.