Assessment of Respiratory Function in Infants and Young Children Wearing Face Masks During the COVID-19 Pandemic

Effective volume of rebreathed air during breathing with facepieces increases with protection class and decreases with ambient airflow

Wearing facepieces is discussed in the context of increasing the volume of rebreathed air. We hypothesized that rebreathed air volume increases with increasing filtering facepiece (FFP) class and that persons breathing via facepieces compensate for the additional dead-space. We have determined the effective amount of rebreathed air for a surgical masks and FFP2 and FFP3 respirators in a physical model and determined tidal volumes, breathing frequency, blood oxygen saturation, and transcutaneously measured blood carbon dioxide partial pressure (PCO2) in lung-healthy subjects breathing without and with facepieces at rest and during exercising on a recumbent ergometer. Rebreathed air volume increased with the facepieces' protection class and with increasing inspiration volume by 45 ± 2 ml to 247 ± 1 ml. Ambient airflow reduced rebreathed air volume by 17% up to 100% (all p < 0.001). When wearing facepieces, subjects increased tidal volume (p < 0.001) but not breathing frequency. Oxygen saturation was not influenced by facepieces. With FFP3 respirators PCO2 increased by up to 3.2 mmHg (p < 0.001) at rest but only up to 1.4 mmHg (p < 0.001) when exercising. Discomfort of breathing increased with increasing protection class of the facepiece but was consistently perceived as tolerable. We conclude that the amount of rebreathed air increases with increasing protection class of facepieces. Healthy adults were capable to compensate the facepieces' dead-space by adapting tidal volume at rest and during physical activity; thereby they tolerated moderate increases in PCO2. Ambient airflow may considerably reduce the amount of facepiece related rebreathed air.

Assessment of mask use on oxygen saturation in adults and children with asthma

Background: Mask use is recommended to reduce the transmission of severe acute respiratory syndrome coronavirus 2. The safety of mask use in adults and children with asthma is unknown. Objective: The objective of this study is to evaluate the effect of mask use on peripheral oxygen saturation (SpO₂) in those with and those without asthma. Methods: A two-stage cross-sectional study was performed. In the first stage, the SpO₂ concentration in adults and children with and without asthma was measured with the adults and children at rest during mask use. In the second stage, children years 6-17 performed a 6-minute walk test while wearing masks. The SpO₂ concentration was measured before the exercise and at 3 and 6 minutes into exercise. Subjective dyspnea was evaluated by using the Pediatric Dyspnea Scale (PDS). Results: In the first stage, SpO₂ levels in 393 subjects were analyzed. In the second stage, 50 pediatric subjects were included, 25 with and 25 without asthma. There was no difference in SpO₂ levels between those with and those without asthma in adults and children wearing masks while at rest, with median SpO₂ 98% in both groups. There was no difference in oxygen saturation or reported level of dyspnea between the children with asthma and children without asthma performing the 6-minute walk test while wearing masks. Median SpO₂ levels were at or near 99% in the asthma and non-asthma groups at all time points. Median PDS scores were similar between the asthma and non-asthma groups. Conclusion: Mask use did not affect SpO₂ in adults and children at rest or in children performing low-to-moderate intensity exercise. These findings were consistent in those with and without asthma.

Effect of Facemask in Congenital Central Hypoventilation Syndrome

INTRODUCTION

Congenital central hypoventilation syndrome (CCHS) is a rare genetic disorder with a mutation in the PHOX2B gene. Patients need ventilatory support by noninvasive ventilation or tracheostomy to treat alveolar hypoventilation. Patients with CCHS have a defect in chemosensitivity signal integration. Recently, due to the COVID-19 pandemic, the entire world has had to get used to wearing medical masks (MM).

OBJECTIVES

The aim of the study was to evaluate the effect of an MM on gas exchange and to determine the role of central and peripheral chemoresponsiveness on the partial pressure of transcutaneous carbon dioxide (PtcCO2) in patients with CCHS wearing an MM.

METHODS

This study was based on the analysis of recordings obtained without and with an MM during hospitalization and was conducted to assess the impact of MM on PtcCO2 and SpO2 recordings with the SenTec Digital Monitor and their relationships with peripheral CO2 chemosensitivity obtained during tidal breathing measurement and with the hypercapnic hyperoxic ventilatory response.

RESULTS

Sixteen patients were included (13 boys) and were 10.2 (7.5; 18.5) years old. The use of an MM had a negative impact on gas exchange in patients with CCHS. The median PtcCO2 increased significantly. Peripheral chemosensitivity correlated with MM-induced PtcCO2 changes (R = -0.72, p = 0.005), but central chemosensitivity (the hypercapnic ventilator response slope) did not (R = -0.22, p = 0.510).

CONCLUSION

The use of an MM had a negative impact on gas exchange in patients with CCHS.

Screening of potential biomarkers for polycystic ovary syndrome and identification of expression and immune characteristics

BACKGROUND

Polycystic ovary syndrome (PCOS) seriously affects the fertility and health of women of childbearing age. We look forward to finding potential biomarkers for PCOS that can aid clinical diagnosis.

METHODS

We acquired PCOS and normal granulosa cell (GC) expression profiles from the Gene Expression Omnibus (GEO) database. After data preprocessing, differentially expressed genes (DEGs) were screened by limma package, and Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analysis and Gene Set Enrichment Analysis (GSEA) were performed. Recursive feature elimination (RFE) algorithm and the least absolute shrinkage and selection operator (LASSO) Cox regression analysis were used to acquire feature genes as potential biomarkers. Time-dependent receiver operator characteristic curve (ROC curve) and Confusion matrix were used to verify the classification performance of biomarkers. Then, the expression characteristics of biomarkers in PCOS and normal cells were analyzed, and the insulin resistance (IR) score of samples was computed by ssGSEA. Immune characterization of biomarkers was evaluated using MCP counter and single sample gene set enrichment analysis (ssGSEA). Finally, the correlation between biomarkers and the scores of each pathway was assessed.

RESULTS

We acquired 93 DEGs, and the enrichment results indicated that most of DEGs in PCOS group were significantly enriched in immune-related biological pathways. Further screening results indicated that JDP2 and HMOX1 were potential biomarkers. The area under ROC curve (AUC) value and Confusion matrix of the two biomarkers were ideal when separated and combined. In the combination, the training set AUC = 0.929 and the test set AUC = 0.917 indicated good diagnostic performance of the two biomarkers. Both biomarkers were highly expressed in the PCOS group, and both biomarkers, which should be suppressed in the preovulation phase, were elevated in PCOS tissues. The IR score of PCOS group was higher, and the expression of JDP2 and HMOX1 showed a significant positive correlation with IR score. Most immune cell scores and immune infiltration results were significantly higher in PCOS. Comprehensive analysis indicated that the two biomarkers had strong correlation with immune-related pathways.

CONCLUSION

We acquired two potential biomarkers, JDP2 and HMOX1. We found that they were highly expressed in the PCOS and had a strong positive correlation with immune-related pathways.

Physiologic effects of surgical masking in children versus adults

Background

Surgical masks remain a focal part of the CDC guidelines to decrease COVID-19 transmission. Evidence refuting significant effects of masking on ventilation is mostly limited to small studies, with a paucity of studies on children, and none comparing children to adults.

Methods

A total of 119 subjects were enrolled (71 adults, 49 children) in a prospective interventional study with each subject serving as their own mask-free control. End tidal CO2 (ETCO2), inspired CO2 (ICO2), and respiratory rate were measured by nasal cannula attached to an anesthesia machine D-fend module. Pulse oximetry and heart rate were also followed. After the mask-free period, an ASTM Level 3 disposable surgical mask was donned and 15 min of mask-worn data were collected.

Results

A steady state was confirmed for ETCO2 and ICO2 over the masked period, and mean ICO2 levels rose significantly (p < 0.001) after masking in all age groups. The increase in ICO2 for the 2- to 7-year-old group of 4.11 mmHg (3.23-4.99), was significantly higher (p < 0.001) than the final ΔICO2 levels for both the 7- to 14-year-old group, 2.45 mmHg (1.79-3.12), and adults, 1.47 mmHg (1.18-1.76). For the pediatric group there was a negative, significant correlation between age and ΔICO2, r = -0.49, p < 0.001. Masking resulted in a statistically significant (p < 0.01) rise in ETCO2 levels of 1.30 mmHg in adults and 1.36 mmHg in children. The final respective ETCO2 levels, 34.35 (33.55-35.15) and 35.07 (34.13-36.01), remained within normal limits. Pulse oximetry, heart rate, and respiratory rate were not significantly affected.

Discussion

The physiology of mechanical dead space is discussed, including the inverse relationship of subject age vs ICO2. The methodology and results are compared to previously published studies which detracted from the physiologic safety of surgical masking.

Conclusions

The wearing of a surgical mask results in a statistically significant rise in ICO2 and a smaller rise in ETCO2. Because ETCO2 and other variables remain well within normal limits, these changes are clinically insignificant.

Influence of Mask Wearing during COVID-19 Surge and Non-Surge Time Periods in Two K-12 Public School Districts in Georgia, USA

BACKGROUND

Into the third year of the COVID-19 pandemic and the second year of in-person learning for many K-12 schools in the United States, the benefits of mitigation strategies in this setting are still unclear. We compare COVID-19 cases in school-aged children and adolescents between a school district with a mandatory mask-wearing policy to one with an optional mask-wearing policy, during and after the peak period of the Delta variant wave of infection.

METHODS

COVID-19 cases during the Delta variant wave (August 2021) and post the wave (October 2021) were obtained from public health records. Cases of K-12 students, stratified by grade level (elementary, middle, and high school) and school districts across two counties, were included in the statistical and spatial analyses. COVID-19 case rates were determined and spatially mapped. Regression was performed adjusting for specific covariates.

RESULTS

Mask-wearing was associated with lower COVID-19 cases during the peak Delta variant period; overall, regardless of the Delta variant period, higher COVID-19 rates were seen in older aged students.

CONCLUSION

This study highlights the need for more layered prevention strategies and policies that take into consideration local community transmission levels, age of students, and vaccination coverage to ensure that students remain safe at school while optimizing their learning environment.

Possible toxicity of chronic carbon dioxide exposure associated with face mask use, particularly in pregnant women, children and adolescents - A scoping review

Introduction

During the SARS-CoV-2-pandemic, face masks have become one of the most important ubiquitous factors affecting human breathing. It increases the resistance and dead space volume leading to a re-breathing of CO2. So far, this phenomenon and possible implications on early life has not been evaluated in depth.

Method

As part of a scoping review, literature was systematically reviewed regarding CO2 exposure and facemask use.

Results

Fresh air has around 0.04% CO2, while wearing masks more than 5 min bears a possible chronic exposure to carbon dioxide of 1.41% to 3.2% of the inhaled air. Although the buildup is usually within the short-term exposure limits, long-term exceedances and consequences must be considered due to experimental data. US Navy toxicity experts set the exposure limits for submarines carrying a female crew to 0.8% CO2 based on animal studies which indicated an increased risk for stillbirths. Additionally, mammals who were chronically exposed to 0.3% CO2 the experimental data demonstrate a teratogenicity with irreversible neuron damage in the offspring, reduced spatial learning caused by brainstem neuron apoptosis and reduced circulating levels of the insulin-like growth factor-1. With significant impact on three readout parameters (morphological, functional, marker) this chronic 0.3% CO2 exposure has to be defined as being toxic. Additional data exists on the exposure of chronic 0.3% CO2 in adolescent mammals causing neuron destruction, which includes less activity, increased anxiety and impaired learning and memory. There is also data indicating testicular toxicity in adolescents at CO2 inhalation concentrations above 0.5%.

Discussion

There is a possible negative impact risk by imposing extended mask mandates especially for vulnerable subgroups. Circumstantial evidence exists that extended mask use may be related to current observations of stillbirths and to reduced verbal motor and overall cognitive performance in children born during the pandemic. A need exists to reconsider mask mandates.

Medical Face Masks Do Not Affect Acid-Base Balance Yet Might Facilitate the Transmission of Staphylococcus aureus in Hospital Settings during the COVID-19 Pandemic

INTRODUCTION

Due to the SARS-CoV-2 coronavirus pandemic, the wearing of masks has become a common phenomenon. Most of the undesirable effects of using a protective face covering are usually related to the prolonged time of its wearing, and the adverse consequences of face coverings should be considered two-fold. The aim of the study was to evaluate the rate of contamination of the three types of face coverings (surgical, N95, and FFP2 masks) with the microorganism-aerobic bacteria, yeasts, and molds-after the 3 h exposure time. The study aimed to investigate the effects of wearing FFP2 masks (KN95) on respiratory function and the acid-base balance of the human body.

RESULTS

The presence of S. aureus was confirmed in both nasal carriers and non-carriers which may demonstrate the cross-contamination and spread of this bacterium via hands. S. aureus was found on external and internal surfaces of face masks of each type, and therefore could also be transmitted via hands from external sources. The 3 h exposure time is not sufficient for Gram-negative rods and mold contamination. Moreover, there were no significant differences in most of the parameters studied between the first and second examinations, both in spirometry and capillary blood gas analysis (p > 0.05).

Patient safety implications of wearing a face mask for prevention in the era of COVID-19 pandemic: a systematic review and consensus recommendations

In the past, the use of face masks in western countries was essentially limited to occupational health. Now, because of the COVID-19 pandemic, mask-wearing has been recommended as a public health intervention. As potential side effects and some contraindications are emerging, we reviewed the literature to assess the impact of them in daily life on patient safety and to provide appropriate guidelines and recommendations. We performed a systematic review of studies investigating physiological impact, safety, and risk of masks in predefined categories of patients, which have been published in peer-reviewed journals with no time and language restrictions. Given the heterogeneity of studies, results were analyzed thematically. We used PRISMA guidelines to report our findings. Wearing a N95 respirator is more associated with worse side effects than wearing a surgical mask with the following complications: breathing difficulties (reduced FiO₂, SpO₂^, PaO₂ increased ETCO₂, PaCO₂), psychiatric symptoms (panic attacks, anxiety) and skin reactions. These complications are related to the duration of use and/or disease severity. Difficulties in communication is another issue to be considered especially with young children, older person and people with hearing impairments. Even if benefits of wearing face masks exceed the discomfort, it is recommended to take an "air break" after 1-2 h consecutively of mask-wearing. However, well-designed prospective studies are needed. The COVID-19 pandemic could represent a unique opportunity for collecting large amount of real-world data.

Carbon dioxide rises beyond acceptable safety levels in children under nose and mouth covering: Results of an experimental measurement study in healthy children

Nose and mouth covering (NMC) has been made compulsory for children in many countries during the Covid-19 pandemic. We wanted to determine the average CO₂ levels in inhaled air with NMC in children between age 6 and 17. We used short term measurements under surgical masks and FFP2 masks according to European norm EN 149, compared to baseline in an experimental, intra-individually controlled study over 25 min. CO₂ content was measured every 15 s using an automated dual-wavelength infrared CO₂ measurement device (G100, Geotech, Leamington Spa, UK) over 25 min in a short-term experimental setting, with children seated. After baseline measurement children were provided with two types of commonly worn NMC: surgical masks and FFP2--masks in randomized sequence for 3 min each. We kept ambient CO₂-levels below 1000 parts per million (ppm) through frequent ventilation. We measured breathing frequency and pulse as potential physiological moderator variables. Forty-five children, 25 boys, 20 girls, with a mean age of 10.7 years (standard deviation 2.6) were measured. We measured 13,100 ppm (SD 380) under surgical mask and 13,900 ppm (SD 370) under FFP2 mask in inhaled air. A linear model with age as a covariate showed a highly significant effect of the condition (p < 1*10^-9). We measured 2,700 ppm (SD 100) CO₂ at pre-baseline and 2,800 ppm (SD 100) at post-baseline, a non-significant small difference. Appropriate contrasts revealed that the change was due to the masks only and the difference between the two types of masks was small and not significant. Wearing of NMC (surgical masks or FFP2- -masks) raises CO₂ content in inhaled air quickly to a very high level in healthy children in a seated resting position that might be hazardous to children's health.

Cross-Sectional Survey on BNT162b2 mRNA COVID-19 Vaccine Serious Adverse Events in Children 5 to 11 Years of Age: A Monocentric Experience

Objective: Our aim was to evaluate the safety of COVID-19 vaccine in children resident in the Latina Local Health Authority. Methods: We conducted a telephone survey among children aged 5–11 years receiving BNT162b2 mRNA COVID-19 vaccine between December 15 and 21. The main outcomes included the presence of allergic reactions or anaphylaxis, adverse events after 24–48 h, 7 and 20 days of taking the first and second doses of medications, and documented SARS-CoV-2 infection after vaccination. The information obtained was automatically linked to a spreadsheet and analyzed. Results: 569 children were enrolled. The mean age was 114 ± 4.24 months; there were 251 males in the study. The vaccine showed a favorable safety profile; no anaphylaxis or serious adverse events were reported. The most common symptoms both after the first and second dose were injection site reactions, asthenia, and headache. Injection site reactions were more frequent after the first dose (p = 0.01), while systemic symptoms were more frequent after the second dose (p = 0.022). These symptoms were more frequent in patients with comorbidities (p = 0.0159). Conclusion: Our findings confirm the safety of COVID-19 vaccine in children younger 11 years and could be useful to promote its diffusion in pediatric ages in order to achieve “herd immunity” and prevent the virus’s circulation.

Assessment of Cardio-Respiratory Function in Overweight and Obese Children Wearing Face Masks during the COVID-19 Pandemic

Objective: To evaluate whether the use of a surgical and N95 mask for overweight and obese children was associated with respiratory distress. Methods: We enrolled 15 healthy and 14 overweight or obese children. We performed two sessions: one wearing a surgical, the other an N95 mask. We tracked changes in partial pressure of end-tidal carbon dioxide (PETCO2), oxygen saturation (SaO2), pulse rate (PR), and respiratory rate (RR) during a 72 min test: 30 min without a mask, 30 min wearing a mask, and then during a 12 min walking test. Results: In healthy children, there was no significant change in SaO2 and PETCO2 during the study; there was a significant increase in PR and RR after the walking test with both the masks. In overweight or obese children, there was no significant change in SaO2 during the study period; there was a significant increase in PETCO2 as fast as wearing the mask and an increase in PETCO2, PR, and RR after walking test. After the walking test, we showed a significant correlation between PETCO2 and body mass index. Conclusion: Overweight or Obese children who wear a mask are more prone to developing respiratory distress, which causes them to remove it frequently. In a crowded environment, they are at greater risk of infection. For this reason, it is desirable that they attend environments where everyone uses a mask.

Adenomesenteritis following SARS-CoV-2 Vaccination in Children: A Case Report and Review of The Literature

At present, the vaccine authorized in children aged 5 years and older is the BNT162b2 messenger RNA COVID-19 vaccine. Unlike adults, there is limited data available in the pediatric age describing adverse events after vaccine. We report a case of adenomesenteritis in a young girl following the first dose of vaccine.

Coronavirus disease 2019 transmission and symptoms in young children during the severe acute respiratory syndrome coronavirus 2 Delta variant and Omicron variant outbreaks

Objective

Little is known about the transmission of coronavirus disease 2019 (COVID-19) in young children. This study aimed to clarify the risk of COVID-19 transmission among this population.

Methods

Between July 2020 and April 2022, 1660 0 to 3-year-old children underwent a nasopharyngeal swab for later reverse transcription-polymerase chain reaction testing at a mass screening test center in Japan. Their disease transmission rate and clinical symptoms were evaluated according to the predominant variant strains of that season.

Results

The secondary transmission rate after close contact of the Delta B.1.617.2 (17.4%) and Omicron B.1.1.529 (39.2%) variants was significantly higher than that of the conventional strains (B.1.1.284 and B.1.1.214; 4.5%) during the pandemic. The increased transmissibility with the Delta and Omicron variants was independent of close contact or location. The prevalence rates of cough, fatigability, and fever were similar in young children infected by the Delta and Omicron variants.

Conclusions

COVID-19 transmission in children aged 0 to 3 years increased by 3 to 4 fold during the Delta outbreak and by 8 to 10 fold during the Omicron outbreak compared with the conventional strain outbreak. The symptoms in young children were not different between the Delta and Omicron variants.

Clinical picture and long-term symptoms of SARS-CoV-2 infection in an Italian pediatric population

Background

SARS-CoV-2 infection in the pediatric age group has a milder course than in adults, but in some cases even children may present with severe forms or develop long-term consequences. The aim of this study was to analyze the clinical features, long-term effects, lifestyle changes and psychological effects of SARS-CoV-2 infection in a pediatric sample of the Italian population.

Methods

We conducted a telephone survey among 3075 children infected with SARS-CoV-2 in the Latina Local Health Authority. Outcomes included: clinical features of infection, long-term symptoms, lifestyle changes and emotional symptoms during the illness. The information obtained was automatically linked to a spreadsheet and analyzed.

Results

One thousand four hundred thirteen children agreed to participate in the study; the mean age was 112.8 ± 21.9 months. Children were infected mainly inside familial clusters (59.6%; n = 842); 99% (n = 1399) of children were asymptomatic or exhibited mild symptoms. 20% (n = 259) of children experienced long-term symptoms; risk factors were: older age, higher body mass index and longer duration of infection.

Throughout the period of infection, children spent most of the time on devices like tv-video, social media and mobile phone for non-educational activities. 58.8% (n = 620) of parents expressed a negative opinion about distance learning. Finally, we observed that 49,6% (n = 532) of children experienced psychological symptoms during quarantine period.

Conclusion

Despite a lower susceptibility to COVID-19 in children, it is important to keep the focus high in children, both because of the possible long symptoms after infection and the impact on a children’s mental and physical health due to pandemic. We believe that the return to school or other extracurricular activities are important to correct some of the risk factors for the long COVID syndrome, as obesity, and to limit the cultural damage generated by distance learning and psychological effects related to restrictive measures.

The Physiological Effects of Face Masks During Exercise Worn Due to COVID-19: A Systematic Review

CONTEXT

Use of facemasks in sport has been a particularly complex issue during the COVID-19 pandemic.

OBJECTIVES

A systematic review to examine the physiological effects the different types of masks have on healthy adults when doing physical exercise.

DATA SOURCES

PubMed, SPORTDiscus, Scopus, and Litcovid were searched up to March 20, 2021, following the PRISMA model. Articles published in the last 5 years with healthy adults.

STUDY SELECTION

A total of 633 studies related to the use of masks during physical exercise were found, of which 8 articles met the criteria to be included.

STUDY DESIGN

Systematic review.

LEVEL OF EVIDENCE

Level 2.

DATA EXTRACTION

The search process and the review of the articles were carried out by independent expert researchers. The risk of bias and the methodological quality of the different studies included in the systematic review were calculated following the Cochrane criteria using an adaptation for random cross-studies. Once the information was properly structured, the results were extracted, and the findings of the study analyzed.

RESULTS

There were significant changes in the following physiological variables when engaging in physical exercise using masks: 25% in the heart rate and dyspnea, 37.5% in the rating of perceived exertion, 50% in the pulmonary variables, and 37.5% in discomfort. The oxygen saturation, blood pressure, systolic blood pressure, diastolic blood pressure, and the concentration of blood lactate did not present any significant effect in this study.

CONCLUSIONS

The usage of masks by a healthy adult population during the performance of physical exercise has shown minimal effects with regard to physiological, cardiorespiratory, and perceived responses. Some symptoms can be dyspnea, effort perceived, or discomfort, among others. These findings indicate that the use of masks is not harmful to individuals' health. It does not present any significant detrimental effect on physical performance or risk to their well-being. However, further experiments are required to corroborate the findings of this review.

Mask mandates for children during the COVID-19 pandemic: an international human rights perspective

Epidemiological and physical safety issues form the core of the debate on whether children should be mandated to wear face masks during the COVID-19 pandemic. Largely absent from this debate are the crucial implications of international human rights law. Although the World Health Organization and the United Nations Children's Fund have different mask-wearing recommendations for children aged 0-5 years, 6-11 years, and 12+ years, the UN Convention on the Rights of the Child applies to children of all ages. Children's human rights under the UN Convention on the Rights of the Child and other treaties require decision makers to tread particularly carefully when deciding whether to mandate mask-wearing for children. Special consideration must be given to the potential for any detrimental impact of mask-wearing on children's physical, psychological and psychosocial health and wellbeing. Other non-pharmaceutical interventions for children, such as physical distancing, good hand hygiene and improved indoor ventilation do not engage the legal complexities of mask-wearing and are a safer policy option for reducing SARS-CoV-2 transmission.

School Asthma Care During COVID-19: What We Have Learned and What We Are Learning

The focus of this article is to review school asthma care during coronavirus disease 2019 (COVID-19). Asthma is listed as a risk factor in some guidelines, although children with asthma appear to not be at increased risk of severe respiratory outcomes compared with children without asthma during the pandemic. Differentiating COVID-19 from allergic disease is very difficult in the school-aged children. For school management, there is firm evidence that masks do not exacerbate underlying lung conditions including asthma, and evidence to date supports that children with asthma can learn in-person at school because they do not appear to be at increased risk of COVID-19 morbidity or mortality. For children and adolescents, the COVID-19 vaccine has been demonstrated to be safe and well tolerated. School asthma management includes remaining on prescribed asthma medications. Asthma management, as with management of all pediatric conditions, must also factor in the impact of adverse social determinants and health disparities. Broadly, the pandemic has also served as a call to resource stewardship and innovation and allowed practitioners to consider how this may impact asthma care moving forward.

To Mask or Not to Mask—Evaluation of Cognitive Performance in Children Wearing Face Masks during School Lessons (MasKids)

In the current SARS-CoV-2 pandemic, wearing a face mask is mandatory again during school lessons. There are no controlled studies in children to date indicating an effect on cognitive performance from wearing face masks. In a randomized controlled trial, we analysed the influence of face masks on cognitive performance of pupils during regular school lessons. Pupils (n = 133, fifth to seventh grade) were randomized by alternating allocation into control (with masks, n = 65) and intervention groups (without mask, n = 68). After two school lessons with (control) and without (intervention) face masks in class, all pupils performed digital tests for cognitive performance regarding attention and executive functions (switch, Corsi block-tapping, 2-back and flanker task). Overall, there were no significant differences in cognitive performance between both groups, masks vs. no masks. Wearing face masks has no significant influence on attention and executive functions of pupils and can still be recommended during school lessons.

Association of Child Masking With COVID-19-Related Closures in US Childcare Programs

IMPORTANCE

It is not known how effective child masking is in childcare settings in preventing the transmission of SARS-CoV-2. This question is critical to inform health policy and safe childcare practices.

OBJECTIVE

To assess the association between masking children 2 years and older and subsequent childcare closure because of COVID-19.

DESIGN, SETTING, AND PARTICIPANTS

A prospective, 1-year, longitudinal electronic survey study of 6654 childcare professionals at home- and center-based childcare programs in all 50 states was conducted at baseline (May 22 to June 8, 2020) and follow-up (May 26 to June 23, 2021). Using a generalized linear model (log-binomial model) with robust SEs, this study evaluated the association between childcare program closure because of a confirmed or suspected COVID-19 case in either children or staff during the study period and child masking in both early adoption (endorsed at baseline) and continued masking (endorsed at baseline and follow-up), while controlling for physical distancing, other risk mitigation strategies, and program and community characteristics.

EXPOSURES

Child masking in childcare programs as reported by childcare professionals at baseline and both baseline and follow-up.

MAIN OUTCOMES AND MEASURES

Childcare program closure because of a suspected or confirmed COVID-19 case in either children or staff as reported in the May 26 to June 23, 2021, end survey.

RESULTS

This survey study of 6654 childcare professionals (mean [SD] age, 46.9 [11.3] years; 750 [11.3%] were African American, 57 [0.9%] American Indian/Alaska Native, 158 [2.4%] Asian, 860 [12.9%] Hispanic, 135 [2.0%] multiracial [anyone who selected >1 race on the survey], 18 [0.3%] Native Hawaiian/Pacific Islander, and 5020 [75.4%] White) found that early adoption (baseline) of child masking was associated with a 13% lower risk of childcare program closure because of a COVID-19 case (adjusted relative risk, 0.87; 95% CI, 0.77-0.99), and continued masking for 1 year was associated with a 14% lower risk (adjusted relative risk, 0.86; 95% CI, 0.74-1.00).

CONCLUSIONS AND RELEVANCE

This survey study of childcare professionals suggests that masking young children is associated with fewer childcare program closures, enabling in-person education. This finding has important public health policy implications for families that rely on childcare to sustain employment.

Effects of surgical facemasks on perceived exertion during submaximal exercise test in healthy children

Only a few data associated to wearability of facemask during exercise are available in children. The aim of the study was to evaluate the effect of wearing a facemask on perceived exertion (primary aim), dyspnea, physical performance, and cardiorespiratory response during a submaximal exercise test in children aged between 8 and 12 years. This study was performed in 2021 in healthy volunteer children from 8 to 12 years. They performed prospectively two 1-min sit-to-stand tests (STST), with or without a surgical facemask. The perceived exertion (modified Borg scale), dyspnea (Dalhousie scale), heart rate, and pulsed oxygen saturation were recorded before and after STST. The STST measured the submaximal performance. Thirty-eight healthy children were recruited (8-9 years: n = 19 and 10-11 years: n = 19). After the STST, the perceived exertion increased with or without a facemask (8-9 years group: + 1 [0.6; 1.4] and + 1.6 [1.0; 2.1] - 10-11 years group: + 1.3 [0.7; 1.8] and + 1.9 [1.3; 2.6]) and it was higher with the facemask. The difference between the two conditions in perceived exertion was not clinically relevant in any group (mBorgf: 0.56 pts and 0.68 pts, respectively). The different domains of dyspnea assessed with Dalhousie scale were not influenced by the facemask. The submaximal performance measured by the STST was not changed by the mask whatever the age group. The cardio-respiratory demand was not clinically modified.Conclusion: The surgical facemask had no impact on dyspnea, cardiorespiratory parameters, and exercise performance during a short submaximal exercise in healthy children.

Cloth face mask fit and function for children part one: design exploration

Commercially available children’s cloth masks range widely in material type and fabric structures, methods of construction, layering, and shape, and there is a lack of sizing systems, anthropometric data or guidelines specifically targeting the fit assessment and design of cloth face masks for children 4-6 years old. To better identify and understand the cloth face mask fit and functional needs of children ages 4-6 years old, the researchers embarked on interdisciplinary in-depth study to investigate commercial market offerings of children’s face masks, identify consumer perspectives, and explore mask design improvements through design research. By triangulating results from survey feedback, commercial market content analysis, and wear trial observations, the researchers were able to identify important design criteria that can be used in the improvement of children’s cloth face mask design: size, comfort, dexterity, movement, and thermal comfort. These criteria were used to iteratively develop new mask prototypes involving a 3D printed head form, traditional sewing and hand patternmaking skills, and the creation of multiple mask versions to explore the design criteria listed above. The designs were interpreted through Bye’s (2010) Problem-Based Design Research (PBDR) framework, which identifies common design research practices in the field on a spectrum and situates PBDR as a process centered on a problem as impetus for design through which artifacts are developed.

Inhaled CO2 Concentration While Wearing Face Masks: A Pilot Study Using Capnography

BACKGROUND

Face masks are recommended based on the assumption that they protect against SARS-CoV-2 transmission, however studies on their potential side effects are still lacking. We aimed to evaluate the inhaled air carbon dioxide (CO₂) concentration, when wearing masks.

METHODS

We measured end-tidal CO₂ using professional side-stream capnography, with water-removing tubing, (1) without masks, (2) wearing a surgical mask, and (3) wearing a FFP2 respirator (for 5 minutes each while seated after 10 minutes of rest), in 146 healthy volunteers aged 10 to 90 years, from the general population of Ferrara, Italy. The inhaled air CO₂ concentration was computed as: ([mask volume × end-tidal CO₂] + [tidal volume - mask volume] × ambient air CO₂)/tidal volume.

RESULTS

With surgical masks, the mean CO₂ concentration was 7091 ± 2491 ppm in children, 4835 ± 869 in adults, and 4379 ± 978 in the elderly. With FFP2 respirators, this concentration was 13 665 ± 3655 in children, 8502 ± 1859 in adults, and 9027 ± 1882 in the elderly. The proportion showing a CO₂ concentration higher than the 5000 ppm (8-hour average) acceptable threshold for workers was 41.1% with surgical masks, and 99.3% with FFP2 respirators. Adjusting for age, gender, BMI, and smoking, the inhaled air CO₂ concentration significantly increased with increasing respiratory rate (mean 10 837 ±3712 ppm among participants ⩾18 breaths/minute, with FFP2 respirators), and among the minors.

CONCLUSION

If these results are confirmed, the current guidelines on mask-wearing should be reevaluated.

Diffusion of COVID-19 among children and adolescents during the second and third waves of the pandemic in Italy

This paper explores COVID-19 diffusion among children and adolescents (up to 19 years old) in Italy using the publicly available data that were collected and released by the Italian National Institute of Health (ISS). We consider in more detail the so-called second and third waves of the pandemic in Italy and explore the relationship between schools opening and the diffusion of COVID-19, which is a highly debated topic in the recent reference literature. We analyse the dynamics of COVID-19 incidence in the country as a whole and in its individual regions. Moreover, we compare the regions in which different levels of restrictions were imposed during the pandemic as well as different school closure calendars. We found there to be a significant correlation between the dynamics of the COVID-19 infections among young people in Italy and school closures during both the second and the third waves of the pandemic.

CONCLUSION

Specifically, we found school closures to have mitigated the spread of the infection, especially among patients between the ages of 14 and 19.

WHAT IS KNOWN

• The relationship between the opening of schools and the diffusion of COVID-19 is a debated topic. • SARS-CoV-2 diffusion among school-aged adolescents is almost twice as that among children. • SARS-CoV-2 is a mild disease for infants and children.

WHAT IS NEW

• We analysed original data on the diffusion of COVID-19 among children and adolescents in Italy. • We calculated incidence of COVID-19 with reference to school-age classes and compared over time in the whole country and in the regions of Italy. • We analysed incidence dynamics considering school closures and other restrictions imposed by the local and national authorities to limit virus diffusion.

Inhaled CO2 Concentration While Wearing Face Masks: A Pilot Study Using Capnography

BACKGROUND

Face masks are recommended based on the assumption that they protect against SARS-CoV-2 transmission, however studies on their potential side effects are still lacking. We aimed to evaluate the inhaled air carbon dioxide (CO₂) concentration, when wearing masks.

METHODS

We measured end-tidal CO₂ using professional side-stream capnography, with water-removing tubing, (1) without masks, (2) wearing a surgical mask, and (3) wearing a FFP2 respirator (for 5 minutes each while seated after 10 minutes of rest), in 146 healthy volunteers aged 10 to 90 years, from the general population of Ferrara, Italy. The inhaled air CO₂ concentration was computed as: ([mask volume × end-tidal CO₂] + [tidal volume - mask volume] × ambient air CO₂)/tidal volume.

RESULTS

With surgical masks, the mean CO₂ concentration was 7091 ± 2491 ppm in children, 4835 ± 869 in adults, and 4379 ± 978 in the elderly. With FFP2 respirators, this concentration was 13 665 ± 3655 in children, 8502 ± 1859 in adults, and 9027 ± 1882 in the elderly. The proportion showing a CO₂ concentration higher than the 5000 ppm (8-hour average) acceptable threshold for workers was 41.1% with surgical masks, and 99.3% with FFP2 respirators. Adjusting for age, gender, BMI, and smoking, the inhaled air CO₂ concentration significantly increased with increasing respiratory rate (mean 10 837 ±3712 ppm among participants ⩾18 breaths/minute, with FFP2 respirators), and among the minors.

CONCLUSION

If these results are confirmed, the current guidelines on mask-wearing should be reevaluated.

Personal Interventions to Reduce Exposure to Outdoor Air Pollution

Unhealthy levels of air pollution are breathed by billions of people worldwide, and air pollution is the leading environmental cause of death and disability globally. Efforts to reduce air pollution at its many sources have had limited success, and in many areas of the world, poor air quality continues to worsen. Personal interventions to reduce exposure to air pollution include avoiding sources, staying indoors, filtering indoor air, using face masks, and limiting physical activity when and where air pollution levels are elevated. The effectiveness of these interventions varies widely with circumstances and conditions of use. Compared with upstream reduction or control of emissions, personal interventions place burdens and risk of adverse unintended consequences on individuals. We review evidence regarding the balance of benefits and potential harms of personal interventions for reducing exposure to outdoor air pollution, which merit careful consideration before making public health recommendations with regard to who should use personal interventions and where, when, and how they should be used. Expected final online publication date for the Annual Review of Public Health, Volume 43 is April 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Considerations for the Safe Operation of Schools During the Coronavirus Pandemic

During the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, providing safe in-person schooling has been a dynamic process balancing evolving community disease burden, scientific information, and local regulatory requirements with the mandate for education. Considerations include the health risks of SARS-CoV-2 infection and its post-acute sequelae, the impact of remote learning or periods of quarantine on education and well-being of children, and the contribution of schools to viral circulation in the community. The risk for infections that may occur within schools is related to the incidence of SARS-CoV-2 infections within the local community. Thus, persistent suppression of viral circulation in the community through effective public health measures including vaccination is critical to in-person schooling. Evidence suggests that the likelihood of transmission of SARS-CoV-2 within schools can be minimized if mitigation strategies are rationally combined. This article reviews evidence-based approaches and practices for the continual operation of in-person schooling.

Change in Pediatric Health Care Spending and Drug Utilization during the COVID-19 Pandemic

Objective: To evaluate how the restrictive measures implemented during the SARS-CoV-2 pandemic have influenced the incidence of the most common children’s diseases and the consumption of medications in 2020 compared to 2019. Methods: We involved all family pediatricians of the local health authority of Latina, from which we requested data of monthly visits in 2019 and 2020 for six common diseases disseminated through droplets and contact, and the territorial and integrative pharmaceutical unit of the area, from which we requested data of the net expenditure regarding the most commonly used drugs at pediatric age. Results: There was significant reduction in the incidence of the evaluated diseases and in the consumption of investigated drugs between 2019 and 2020 in the months when the restrictive measures were in place, with an attenuation of this effect during the months of the gradual loosening of those measures. Conclusion: Nonpharmaceutical intervention measures have caused changes in the diffusion of common pediatric diseases. We believe that the implementation of a reasonable containment strategy, even outside of the pandemic, could positively influence the epidemiology of infectious and allergic diseases in children, and healthcare system spending.

Methodological problems of SARS-CoV-2 rapid point-of-care tests when used in mass testing

The aim of the current study is to perform model calculations on the possible use of SARS-CoV-2-rapid point-of-care tests as mass tests, using the quality criteria extracted from evidence-based research as an example for the Federal Republic of Germany. In addition to illustrating the problem of false positive test results, these calculations are used to examine their possible influence on the 7-day incidence. For a substantial period of time, this parameter formed the decisive basis for decisions on measures to protect the population in the wake of the COVID pandemic, which were taken by the government. Primarily, model calculations were performed for a base model of 1,000,000 SARS-CoV-2-rapid point-of-care tests per week using various sensitivities and specificities reported in the literature, followed by sequential testing of the test positives obtained by a SARS-CoV-2 PCR test. Furthermore, a calculation was performed for an actual maximum model based on self-test contingents by the German Federal Ministry of Health. Assuming a number of 1,000,000 tests per week at a prevalence of 0.5%, a high number of false positive test results, a low positive predictive value, a high negative predictive value, and an increase in the 7-day incidence due to the additional antigen rapid tests of approx. 5/100,000 were obtained. A previous maximum calculation based on contingent numbers for self-tests given by the German Federal Ministry of Health even showed an additional possible influence on the 7-day incidence of 84.6/100,000. The model calculations refer in each case to representative population samples that would have to be drawn if the successive results were comparable which should be given, as far-reaching actions were based on this parameter. The additionally performed SARS-CoV-2-rapid point-of-care tests increase the 7-day incidence in a clear way depending on the number of tests and clearly show their dependence on the respective number of tests. SARS-CoV-2-rapid point-of-care tests as well as the SARS-CoV-2-PCR test method should both be used exclusively in the presence of corresponding respiratory symptoms and not in symptom-free persons.

Assessment of respiratory function in children wearing a N95 mask with or without an exhalation valve: Data compared

In response to the current COVID-19 pandemic, universal face masking represents one of the most important strategies to limit the spread of infection. However, their use in children is still highly debated (Esposito and Principi, 2020; Esposito et al., 2020) and there are few data (Lubrano et al., 2021a, 2021b) describing their possible effects on respiratory function in children. A dataset in this paper presents a comparison of the data related to the effects on respiratory function of children wearing a filtering facepiece 2 (N95 mask) with or without exhalation valve. 22 healthy children were randomly assigned to two groups, both groups wearing an N95 mask: one without an exhalation valve (group A), another with an exhalation valve (group B). Children were subjected to a 72 min test: the first 30 min without mask, then 30 min wearing face mask while practiced their usual play activity; finally, 12 min, with face mask in place, while they walked as in a walking test. They were monitored through to microstream capnography system (Rad-97TM with Nomo-Line Capnography, Masimo, Irvine, CA, USA) to log oxygen saturation (SpO2) and respiratory rate (RR). We use the Wilcoxon test to analyzed the differences between the parameters recorded during the study in group A and B. Data analysis was performed using JMP14.3.0 program for Mac by SAS Institute inc.

Effects of N95 Mask Use on Pulmonary Function in Children

OBJECTIVE

To assess whether use of an N95 mask by children is associated with episodes of desaturation or respiratory distress.

STUDY DESIGN

Twenty-two healthy children were assigned at random to 1 of 2 groups: one group wearing N95 masks without an exhalation valve and the other group wearing N95 masks with an exhalation valve. We tracked changes in partial pressure of end-tidal carbon dioxide (P_ETCO2), oxygen saturation, pulse rate, and respiratory rate over 72 minutes of mask use. All subjects were monitored every 15 minutes, the first 30 minutes while not wearing a mask and the next 30 minutes while wearing a mask. They then performed a 12-minute walking test.

RESULTS

The children did not experience a statistically significant change in oxygen saturation or pulse rate during the study. There were significant increases in respiratory rate and P_ETCO2 in the children wearing an N95 mask without an exhalation valve, whereas these increases were seen in the children wearing a mask with an exhalation valve only after the walking test.

CONCLUSIONS

The use of an N95 mask could potentially cause breathing difficulties in children if the mask does not have an exhalation valve, particularly during a physical activity. We believe that wearing a surgical mask may be more appropriate for children.

COVID-19 false dichotomies and a comprehensive review of the evidence regarding public health, COVID-19 symptomatology, SARS-CoV-2 transmission, mask wearing, and reinfection

Scientists across disciplines, policymakers, and journalists have voiced frustration at the unprecedented polarization and misinformation around coronavirus disease 2019 (COVID-19) pandemic. Several false dichotomies have been used to polarize debates while oversimplifying complex issues. In this comprehensive narrative review, we deconstruct six common COVID-19 false dichotomies, address the evidence on these topics, identify insights relevant to effective pandemic responses, and highlight knowledge gaps and uncertainties. The topics of this review are: 1) Health and lives vs. economy and livelihoods, 2) Indefinite lockdown vs. unlimited reopening, 3) Symptomatic vs. asymptomatic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, 4) Droplet vs. aerosol transmission of SARS-CoV-2, 5) Masks for all vs. no masking, and 6) SARS-CoV-2 reinfection vs. no reinfection. We discuss the importance of multidisciplinary integration (health, social, and physical sciences), multilayered approaches to reducing risk ("Emmentaler cheese model"), harm reduction, smart masking, relaxation of interventions, and context-sensitive policymaking for COVID-19 response plans. We also address the challenges in understanding the broad clinical presentation of COVID-19, SARS-CoV-2 transmission, and SARS-CoV-2 reinfection. These key issues of science and public health policy have been presented as false dichotomies during the pandemic. However, they are hardly binary, simple, or uniform, and therefore should not be framed as polar extremes. We urge a nuanced understanding of the science and caution against black-or-white messaging, all-or-nothing guidance, and one-size-fits-all approaches. There is a need for meaningful public health communication and science-informed policies that recognize shades of gray, uncertainties, local context, and social determinants of health.

Can Very Young Children Safely Wear Surgical Masks?

Researchers find no evidence of adverse respiratory effects.

Serum IgG levels in children 6 months after SARS-CoV-2 infection and comparison with adults

Since the outbreak of SARS-CoV-2 among the population has occurred quite recently, there is a lack of evidence on the long-term duration of antibody response, especially in children. It is therefore crucial to clarify this aspect, considering its implications in the development of successful surveillance strategies, therapies, and vaccinations. The aim of this study was to assess the antibody response in a children group after SARS-CoV-2 infection, and to compare it with that of their parents affected by SARS-CoV-2 infection. We enrolled 12 children and their parents, both groups being affected by COVID-19 in April 2020. In the children's group, we collected real-time RT-PCR cycle threshold (Ct) values and gene characterization of first nasal-throat swab at the time of diagnosis (T0); 30 days after the diagnosis (T30), we performed blood tests to detect anti-SARS-CoV-2 IgM and IgG. Finally, 180 days after the diagnosis (T180), we measured anti-SARS-CoV-2 IgG in both children and parents. In children, antibody levels declined significantly at 180 days (T180) after first measurement (T30). There were no significant differences in IgG level related to age, sex, and clinical manifestations. We found a significant correlation between IgG titers at T30 and Ct value of gene N. Children showed a lower level of antibodies against SARS-CoV-2 at T180 compared to their parents.Conclusion: Antibody responses in children waned 180 days after SARS-CoV-2 infection, and at the same time, their parents showed a different antibody response to the virus. These results highlight that serological tests should be used with caution in surveillance strategies among the general population. What is known: • Currently is not known how long antibody response will be maintained or if it protects from reinfection. • Recent reports in adults suggest that antibodies to SARS-CoV-2 declined several months after infection, but data are missing in pediatric age. What is new: • We showed that antibody responses to SARS-CoV-2 wane several months after infection also in children with quantitative differences in antibody levels between children and adults. • In this context, serological tests should be used with caution in surveillance strategies.