Guidance for Evaluating a Child’s Medical Tolerance for use of Face Coverings in Schools
As schools consider whether and how to safely re-open during the COVID-19 pandemic, school physicals are an opportunity to assess whether a student is able to medically tolerate the use of a face covering. There are currently many questions regarding the criteria used by pediatric providers to determine whether a child is able to medically tolerate the use of a face covering. In reviewing recommendations from the Centers for Disease Control and Prevention (CDC), the American College of Allergy, Asthma and Immunology, the American Lung Association, and the American Academy of Pediatrics, pediatric providers may determine a child is medically unable to tolerate a face covering for the following main reasons:
- The child has a medical contraindication, e.g., difficulty breathing at rest, and/or
- The child is developmentally (physically or intellectually) disabled, such that they are unable to remove a mask if needed
Students who provide a provider’s note to their school documenting that they are medically unable to tolerate wearing a face covering may use a face shield instead. However, when wearing a face shield, there is need for heightened adherence to strict social distancing (at least 6 feet separation) because face shields do not provide adequate “source control” and are not substitutes for face coverings. Exemptions to the requirement to wear face coverings while in a school should be kept to a minimum and should adhere to the joint DPH and ISBE guidance available at https://www.isbe.net/Documents/Part-3-Transition-Planning-Phase-4.pdf.
Students with an IEP or 504 Plan who are unable to wear either face coverings or face shields due to a medical contraindication may not be denied access to an in-person education if the school is offering in-person education to other students. Staff should wear approved and appropriate PPE (as determined by job-specific duties and risks) and maintain social distance as much as possible when working with students who are unable to wear a face covering or face shield due to a medical contraindication. Other students should also remain socially distant from students who are unable to wear a face covering or face shield due to a medical contraindication. Schools should consult with their local public health department regarding appropriate PPE for these situations. Only those licensed professionals authorized to conduct pediatric health examinations consistent with 105 ILCS 5/27-8.1(2), including physicians licensed to practice medicine in all branches of medicine, licensed advanced practice registered nurses, and licensed physician assistants, may provide a medical note indicating that a student is medically unable to tolerate a face covering or a face shield.
Additional Considerations:
- Children with asthma and other chronic respiratory conditions (e.g., cystic fibrosis) should wear a face covering as they are more susceptible to infections. Such conditions, by themselves, are not an indication that a child is unable to medically tolerate a face covering.
- Behavioral techniques (e.g., cognitive behavioral therapy) may be utilized for children who experience anxiety when wearing a face covering. Parents should consider remote learning options until anxiety resolves and the children learn to wear a face covering.
- Remote learning is recommended for children who are at high risk for infection due to a weakened or compromised immune system or condition or for children who live with an individual who is at high risk for infection due to a weakened or compromised immune system. Physicians should review the Centers for Disease Control and Prevention’s list of those who are at higher risk of severe illness if they are exposed to coronavirus.
Recommendations for Evaluating Symptomatic Individuals
Many of the symptoms of COVID-19 infection are also common in other childhood illnesses. Therefore, every symptomatic person should be evaluated on a case-by-case basis by their healthcare provider and decisions about testing for SARS-CoV-2 should be based on patients’ personal health histories. Healthcare providers are strongly encouraged to test for SARS CoV-2 when patients have had a known exposure or present with any COVID symptom due to the undescriptive clinical presentation of COVID-19, and potential for co-infection. Many COVID-19 cases have been observed in persons who originally discounted their symptoms due to other existing conditions, e.g., allergies. Prompt and early diagnosis of COVID-19 infection can prevent further transmission. Children returning to school after being diagnosed with a non-COVID-19 illness must meet the criteria for returning to school for the illness with which they have been diagnosed. At a minimum, the child must be fever-free for at least 24 hours without the use of fever-reducing medications. Additionally, children who are close contacts to confirmed cases, regardless of symptoms, should be tested.
