When AirPop was founded, children were a key consideration. AirPop's co-founder, Chris, found that his 2-year old and newborn were both suffering from respiratory illnesses in reaction to their local environment at the time, China. Recognising that there were no effective filtration devices for children, Chris took it upon himself to create masks that could provide much-needed protection.
Since then, AirPop has grown significantly. These days, thousands of children around the world are donning our masks. We've also expanded our products and now offer a range of respiratory protection devices for all ages. However, children have always remained one of our key focuses.
While the original danger was air pollution, COVID-19 is now the most immediate threat to which children are being exposed. Having already designed respirators with children as a key consideration, we wanted to address a question that has arisen many times over the past few months - should we be masking our children?
One of the most controversial discussions surrounding masks is whether or not children should even be required to don the devices. However, this conversation also expands to other questions, such as when should masking become essential and how can we pick the best mask for our children?
These questions and more have arisen lately as schools return to physical classes in many countries. But unfortunately, with the ongoing debate, it can be hard to put together the facts from both sides and make an educated decision.
In today's article, we want to make the case that we should be protecting our children and masking them. At this time, high-quality masks and respirators are especially essential for our youngest family members due to the amount of time spent in enclosed and high-risk environments.
While COVID has been found to generally cause less severe symptoms in children, we are still unaware of the long-term implications. As such, we need to do everything we can to ensure that the dangers of COVID do not impact them.
Can COVID-19 Impact Children?
Before going any further, we need to establish whether or not COVID-19 impacts children. While we are still in the process of discovering the exact implications that COVID can lead to, here is what we currently know.
Earlier in the pandemic, it was generally well-known that COVID-19 was less severe in children. This is likely due to a range of factors, including pre-existing immunity to coronaviruses, higher levels of melatonin, differences in innate and adaptive immunity, and more (1).
On top of this, Omicron is inherently milder in young children than Delta (2). This stands true for children and all age groups as Omicron tends to be significantly less severe. When viewed from this perspective, it seems that the impact of Omicron on children is relatively low.
However, Omicron is impacting more children than previous COVID variants. Just under 1000 children per day are being admitted to hospitals due to COVID every day in the U.S alone (3). While Omicron is milder, it’s also more contagious and therefore infects a greater number of children.
Almost one-third of children hospitalized due to COVID-19 require ICU admission or invasive mechanical ventilation (4). Risk factors are increased for children with pre-existing conditions. Conditions such as obesity, chronic lung disease, neurologic disorders, cardiovascular diseases and more can increase the risk factor of COVID on children (4).
Asthma is a common disease that can increase the risk of a severe COVID-19 infection. Unfortunately, this disease is very prevalent and impacts 7% of all children in the U.S (5). With these conditions and more heightening the risk of COVID, we must do our best to minimize the risk for our children.
Another factor that makes COVID such a worry for children is that we are still unsure of the long-term impacts of the disease. Some adults experience symptoms even months after contracting the disease, and there is still limited research showing if or when these symptoms will pass.
King’s College London tracked over 1700 children between September 2020 and February 2021 to discover the longer-term symptoms of COVID-19. Over half of the children followed experienced fatigue, headaches and sore throats. Just under half (43.7%) experienced fevers (6). These symptoms were still affecting children months after they contracted the disease.
These long-term impacts make it especially important to ensure we are protecting children as best as we can. Even in 2022, there are many unknowns regarding the long term impacts of COVID-19. Since children may be impacted by symptoms for years to come, safeguarding their health is of the utmost importance.
- https://pubmed.ncbi.nlm.nih.gov/33262177/
- https://edition.cnn.com/2022/01/14/health/omicron-milder-kids-still-cautious/index.html
- https://www.scientificamerican.com/article/why-omicron-is-putting-more-kids-in-the-hospital/
- https://www.publications.aap.org/pediatrics/article-split/149/1/e2021053418/183463/Risk-Factors-for-Severe-COVID-19-in-Children
- https://www.aafa.org/asthma-facts/
- https://www.webmd.com/lung/long-covid-19-children
Why Masks are Essential for Children
Masks are essential for children for many reasons. A critical factor often mentioned is school, where children are confined in an indoor environment with other children and adults for long periods.
While many other spread prevention methods can be used in classrooms - good ventilation, partitions, and high-efficiency air filters, to name but a few - masks are always a great addition to overall COVID mitigation strategies. Many classrooms are not ideally set up for air circulation, and masks are the only protection method we can implement on an individual level.
Interestingly, classrooms are only considered a medium-risk environment (1). There are actually many other, higher risk environments that children are exposed to regularly. We will discuss these environments in more detail soon.
On top of this, vaccination rates for adolescents and children are still significantly behind adults in most countries. As of writing, only 20% of children between 5-11 years old are fully vaccinated in the U.S (2). While this rate will grow in the future, some countries aren't even at the point of vaccinating children yet.
Earlier in the pandemic, we saw relatively few impacts of COVID in children. Compared to adults, children appeared to be avoiding the most severe implications of the virus. However, with the rise of Omicron, more children are being impacted by the disease.
While there is no conclusion as to why this phenomenon is occurring, experts believe that it is due to the more contagious nature of Omicron paired with the variant's preference for airway passages above the lungs - passages that can be blocked more easily on children (3).
Another factor worth considering is that while children and younger individuals often experience more minor cases of COVID-19, they can transmit the disease to other family members and friends. This can then spread to more at-risk members of our families. Therefore, masks and other mitigation methods can protect our children, but they can also protect our families.
There is ample research showing how effective masks are at reducing the spread of COVID-19. However, recent research has shown that we should not be wearing any masks; we should be donning high-filtration respirators. If you're unsure about the difference between masks and respirators, please refer to our recent article on N95 vs KN95 vs KF94 - what does it all mean?
A recent study (4) has highlighted how superior respirators are for COVID protection. The study compared the risk factor of COVID-19 on a susceptible individual standing near an infected individual speaking. Researchers tested a variety of social distancing and mask combinations.
With the infected individual talking from three metres away, the susceptible individual had a 90% chance of catching the disease within only a few minutes. This test relied only on social distancing, with neither individual donning a mask or respirator.
If the susceptible individual instead dons a surgical mask (but the infected individual does not), this 90% transmission chance occurs after 30 minutes. If the susceptible individual instead dons an FFP2 (or equivalent) respirator, there is only a 20% transmission chance after 1 hour.
If both individuals wear surgical masks, the rate stays at about 30% after one hour. Finally, if both individuals don well-fitting respirators, there is only a 0.4% chance of COVID infecting the susceptible individual after 1 hour.
This study highlights why respirators are so necessary. This is especially pertinent for children who spend a significant amount of time indoors near other children and adults. In such environments, the chances of catching COVID-19 without a respirator are far higher than with a high-filtration device.
Of course, this leads to a common issue - an increase in filtration often leads to a decrease in breathability. This can make wearing respirators a very unpleasant experience not only for children but for everyone. Luckily, there are some comfortable choices that we will discuss in more detail soon.
- https://www.idsociety.org/globalassets/idsa/public-health/covid-19/activity-risk.pdf
- https://www.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/children-and-covid-19-vaccination-trends/
- https://www.scientificamerican.com/article/why-omicron-is-putting-more-kids-in-the-hospital/
- https://www.pnas.org/content/118/49/e2110117118
What Age Should Children Wear Masks from?
In recent times another hot topic of discussion is from what age should children be donning masks. While there is no consensus as to when exactly masks should become mandatory, or at least highly recommended, there is a consensus that children under 2-years of age should not don masks (1).
The CDC recommends that all children older than 2-years of age don masks when at school (2). At the same time, many different organisations recommend that only older children need to don masks. For example, Singapore, France and Italy (among other countries) recommend masks only from 6-years and older (1).
This is similar to the WHO guidelines, which recommend that children between 6-11 years of age don masks when in higher risk environments. However, these children should only wear a mask when they have adult supervision to ensure the children’s safety (3).
WHO also states that children under five years of age should not be required to don masks. Further, children over 12 years of age should wear masks in the same situations that adults would, according to the same guidelines.
These often contradictory guidelines make it very difficult to know whether or not you should be masking your children. If you’re unsure when to mask, we recommend following the WHO guidelines that are used in most countries. Children over the age of 5 should wear a mask when in a high-risk environment and when adult supervision is present. Children over 12 should be donning masks in the same situations as adults.
Of course, it’s also essential to check local guidelines. Mask guidelines change regularly as case numbers rise and fall, and the best way to keep up to date is to check your local regulations. The WHO guidelines are the next best to follow if these are absent.
- https://www.bbc.com/future/article/20211025-how-face-masks-affect-young-children
- https://www.cdc.gov/coronavirus/2019-ncov/community/schools-childcare/k-12-guidance.html
- https://www.who.int/news-room/questions-and-answers/item/q-a-children-and-masks-related-to-covid-19
What Children Should Not Wear Masks?
The consensus for U.S based organisations is that children under two years old should not wear masks. This age is raised to five in many other countries - in line with the WHO guidelines. However, are there any other children that should not be donning masks?
Outside of the age requirements, it’s generally believed that all children should be wearing masks (1). The exception to this rule is children who cannot remove a mask themselves - if this is the case, it’s best to consult with a medical professional.
While research has shown that masks are safe for children to use, some children, in particular, will struggle. For example, children with myopia or skin conditions can experience difficulty wearing masks. If this is the case, and your child is between 2 and 12 years old, a risk-based approach is recommended.
Generally, it is recommended that all children over the age of 5 don masks. However, there are exceptions to this, and it’s essential to consult your doctor or licensed medical professional for expert advice.
- https://kidshealth.org/en/parents/coronavirus-masks.html
What High-Risk Environments are Children Exposed to?
The Infectious Disease Society of America has categorised a range of environments into three categories - high risk, medium risk and low risk (1). Locations in each category are based on the assumption that face masks are being worn and that physical distancing of 6 feet or more is being maintained.
High-risk environments that children are likely to be exposed to are high-contact and full-contact sports such as basketball and football, eating at restaurants, attending a place of worship (with singing), and going to movie theatres. Essentially, anywhere involving large crowds or close contact is considered high risk, especially indoor environments.
Medium risk areas include public transportation, playgrounds, theme parks, low contact sports, swimming pools, and, most importantly, schools and malls. But, of course, these are considered medium risk only when masks are worn, and social distancing measures are followed.
Low-risk environments include the supermarket, getting take-out food, non-contact sports venues (for example, tennis), going to the beach (or other outdoor areas with ample social distancing) and going for a walk or bike ride.
Considering how many locations frequented by children are high risk even with prevention measures taken, these risk categories highlight how essential masks are. Depending on local laws, masks will already be required in many of these locations. However, even in situations where they are not mandatory, it’s worth donning a comfortable mask on your children if they are over six years old.
It is also worth mentioning that while schools are generally considered medium risk environments, this is based on the assumption that multiple prevention measures are in place. For this to be the case, plastic barriers and good ventilation must be used. On top of this, masks should be mandatory for all students.
If any of these mitigation methods is not present, the risk increases and schools can become a high-risk environment.
- https://www.idsociety.org/globalassets/idsa/public-health/covid-19/activity-risk.pdf
What Masks Should Children Wear?
The time of cloth and surgical masks has passed. With respirator supply chains back in place, it’s easy for everyone to get their hands on high-filtration respirators. This is also true for children, especially in high-risk environments.
The issue that many of us have experienced is that respirators are typically not that comfortable. They often have high breathing resistance and require a tight fit to perform which can cause pain behind the wearer’s ears.
For us adults, we can force ourselves to don masks and wear them for hours on end even if they are uncomfortable. However, children are a different matter - if a mask is uncomfortable, it's almost impossible to make your child wear it. Not only this, but an uncomfortable mask is simply not pleasant to wear.
Many people will never experience breathable, high-quality respirators and will extend their previous, poor experiences with respirators to all devices. However, while this experience may hold for many respirators, it doesn't apply to all devices.
Therefore, it's essential to look for more breathable and comfortable respirators that children can wear. The Korean Ministry for Food and Drug Safety certifies KF80, KF94 and KF99 devices in children's sizes. These are an excellent choice for children as they have filtration and the standard also requires high breathability. Recently we focused on these differences in our N95 vs KF94 vs KN95 article.
Masks that adhere to ASTM F3502-21 can be considered, but they have big disadvantages. While the standard focuses heavily on breathability and comfort, level 2 (the highest level) only certifies > 50% filtration. As such, masks that adhere to this standard are not ideal for high-risk environments.
Another choice is to use a highly breathable KN95 respirator such as AirPop's Kid respirator. We designed this respirator from the ground up to be comfortable without sacrificing protection. AirPop Kid has half the breathing resistance set by the KN95 certification.
On top of this, AirPop Kid uses a strip of memory foam to create a seal on the nose bridge. This addresses another common issue with respirators, especially for children. Typical wire nosepieces used in high-filtration masks and respirators tend to either be too stiff to mould to a child's nose or too loose and therefore don't keep their fit.
Our AirPop Kid mask addresses comfort and fit by being highly breathable and well-fitting. It's also more environmentally friendly and cheaper in the long term than disposable respirators.
Another key factor to consider is the fit. Fit is essential for good protection, as an ill-fitting mask will not filter particles. Instead, fine particles can simply bypass the mask and enter through leaks between the mask and the child's face. However, another factor to consider is how tightly fitting a mask must be.
Some devices can provide good seals without being overly tight. On the other hand, some devices will require you to pull the earloops incredibly tight before a leak-free seal is obtained. This leads to the mask quickly becoming uncomfortable as it draws on the wearer's ears to seal correctly.
Some masks offset the need for tight earloops by introducing other fitting mechanisms, such as the memory foam used on the AirPop Kid respirator. Adding this strip of foam makes it easier to achieve a leak-free seal without tightening the earloops to an uncomfortable degree.
It can be hard to find a comfortable mask for adults, let alone children. However, there are fantastic masks on the market, and we recommend trying a few to see both what fits best and what is most comfortable for your younger family members.
Conclusion
Whether or not masks are essential for children has been controversial over the past few years. However, with Omicron impacting more children and families than previous strains of COVID-19, masks must be encouraged and worn when needed.
Children under five years old (or two years following CDC guidelines) should not be required to don masks due to the suffocation hazard that they can pose. A risk-based approach is recommended for older children, between five and 12 years of age. If visiting a high-risk location, children should don masks under supervision. Finally, children over the age of 12 should be wearing masks as adults would.
The greatest difficulty in masking children is finding the correct device. Comfort is more important than ever when it comes to masks for children. We adults can often forego comfort for protection, but this is far less often the case among children. Instead, for a child to willingly don a mask, it must be easily breathable and comfortable.
For that reason, it’s essential to focus not only on the filtration and protection factor but also on breathability and comfort. While it can take time to find the ideal mask, it’s worth it in the end, as your child will have a far more pleasant experience.
If you have any questions after reading this post, we recommend getting in touch with a doctor or medical professional. They will give you tailored advice based on you and your child's situation.