Little evidence for facemask use in children against COVID‐19

Abstract

In a Perspective paper in Acta Paediatrica, Xu argues that the pressure on paediatric respiratory departments in Chinese hospitals decreased in early 2020 because children were wearing face masks during the COVID-19 pandemic.1 He concluded that doctors and parents should ask children to wear masks whenever there was a high incidence of respiratory infections, including COVID-19. I feel I should challenge those statements. Most countries seem to have noted reductions in the number children visiting hospitals during the start of the global phase of the pandemic in spring 2020. Decreases have been noted in paediatric emergency departments,2 paediatric asthma wards3 and, in particular, for cases of influenza A.4 But these decreases took place during the early stages of the pandemic, when few countries recommended that children used face masks. From personal experience, fewer children visited emergency departments in Sweden, despite the fact that nobody outside health care was advised to wear face masks.5 The decrease also outside China does not support the suggestion that using face masks explained the reduction in child hospital visits for reasons unrelated to COVID-19 during spring 2020. Although I acknowledge the abundance of studies that suggest that face mask have a protective effect, the evidence may not be as rock-solid as suggested by some face mask supporters. One of the most cited papers so far is the Chu et al systematic review and meta-analysis in The Lancet.6 But this study has some important limitations. Most of the face masks studies that were included looked at other respiratory pathogens, rather than COVID-19. The studies did not include children and very few of the studies were undertaken outside hospital settings. In addition, using face masks in the community and using them in hospitals are very different. It is also worth noting that the supplementary material provided by Chu et al6 also indicated the presence of publication bias, since studies that showed a protective effect of face masks were more likely to be published than negative studies. Asking children to wear face masks may have potential advantages and disadvantages. The potential advantages are clearly a decreased risk of COVID-19 in the child, as well as decreased transmission of the disease. However, it is important to take into account that children rarely become very sick from COVID-19,7 and while so-called multi-inflammatory syndrome8 and potentially also ‘long covid’ occur in children,9 these complications seem rare. Face masks also have potential disadvantages, such as hindering verbal and non-verbal communication. There is a risk that children will keep touching their masks and actually increase the viral load on their hands. Using face masks also risks replacing social distancing, as some parents may be tempted to send their children to school or daycare wearing a mask if they have minor symptoms rather than keeping them at home. Finally, the commercially made masks that are currently available, especially the N95 masks that are said to offer greater protection, rarely fit children. Hence the use of such masks might lead to a false sense of safety, despite leaking viruses due to their poor fit. However, the most important drawback of face masks in children may well be that their use could reduce the focus from other measures that may be more important, such as hand washing, social distancing and staying at home when they are sick. A PubMed search carried out on 10 November 2020, which focused on face masks, COVID-19 and the virus that causes it, identified no paper that offered any guidance on face mask use in children. That said, an absence of evidence is not the same as a lack of effect. If future research suggests that children using face masks decreases COVID-19 morbidity, face masks should be considered in children. But for now, I do not feel we can recommend that children wear face masks, especially since most of the children with COVID-19 get few symptoms7 and do not seem to drive the mortality of the pandemic.10