In Singapore and many other countries around the world, it’s common for young children to wear masks against Covid-19 – but aside from the protection they provide against the virus, might they pose a risk to their longer-term development?
Like many children his age, three-year-old Eshan Evans is energetic and boisterous. But as soon as he has to put on a face mask at school, something changes. “You can see he’s a different boy, much tamer and quieter,” says his mother Herne.
In Singapore, where Eshan and his family live, children aged six and above are legally required to wear masks. But many kindergartens and pre-schools also strongly encourage the practice for younger children. It means that for roughly eight hours every weekday, except while eating, drinking, or napping, Eshan wears a disposable three-ply mask.
The moment he’s let out, however, he rips off his mask, shoving it into his pocket or thrusting into his grandmother’s hands. Once, on a particularly bad day in July, he threw his mask on the ground and ran out the school gates.
“He hates it,” says his mother, who doesn’t make her son wear a mask outside of school. “I have nothing against masks… but we don’t want to force it on him and know he’s uncomfortable.”
The decision of whether to mask young children is one that many parents and regulators around the world are facing as they try to prevent new waves of Covid-19, while also allowing children to develop, socialise and thrive emotionally.
From a regulatory standpoint, as of early October, countries fall largely into three camps. Singapore and European countries such as France and Italy recommend masking up from the age of six. This is in line the World Health Organization’s guidelines, which recommend that children over six wear masks in certain circumstances, for example when there is widespread transmission in their area. Some only apply the rule to specific indoor settings, such as school.
Other regulatory bodies, including the Centers for Disease Control and Prevention in the United States, recommend mask-wearing for those aged two and older. And then there are those countries that have dropped requirements for in-classroom face coverings – for instance, in the UK, neither children nor their teachers are advised to wear masks to school.
The only globally accepted consensus is that babies and children under two should not wear masks, due to the risk of suffocation.
“The age limit for the use of masks by children is not yet a scientific definition,” says Adamos Hadjipanayis, president of the European Academy of Paediatrics.
There have been relatively few studies investigating mask-wearing in children, due to ethical and logistical challenges. Those few studies, which focused on the physical impact of masks on breathing, did not find any harmful effects. But the debate around the wider pros and cons has been heated.
Proponents of mask-wearing argue that masks protect the wearer and those around them from Covid-19, and that the risk factors of the disease for young children should not be overlooked. Most countries do not vaccinate children under 12, or only in exceptional cases, which leaves them comparatively exposed. Serious cases of Covid-19 in young children are still relatively rare – according to a large UK study published this July, roughly one in 50,000 children with Covid end up in intensive care, and two in a million die. But the rapidly spreading Delta variant, which is at least twice as contagious compared with previous strains, is putting pressure on countries to contain and prevent outbreaks, including among children.
“Delta makes the situation far worse,” says Deepti Gurdasani, a clinical epidemiologist at Queen Mary University of London. “Post-Delta, we’re seeing a lot of outbreaks in schools all over the world.”
The good news is that mask-wearing has been linked to lower rates of Covid-19 in schools. For example, in the US state of North Carolina, where masking is compulsory for students above six, schools reported extremely low transmission rates – although more than 7,000 children and staff attended school while carrying the virus between March and June 2021, only 363 Covid-19 cases were found to have been caused as a result.
Masks provide an additional layer of protection against Covid-19 and have been shown to decrease the risk of getting the disease – Annabelle de St. Maurice
In another survey involving 169 elementary schools in Georgia, researchers found that when teachers and staff were required to wear masks, reported Covid-19 cases were 37% lower compared to schools without a mask mandate.
“Masks provide an additional layer of protection against Covid-19 and have been shown to decrease the risk of getting the disease,” says Annabelle de St. Maurice, an assistant professor of paediatrics at the University of California, Los Angeles.
Of course, masking may not solely be responsible for reducing transmission. Other protective factors such as “personal hand hygiene, safe distancing, and whether an area is well-ventilated may play a part,” says Mark Ng, the clinical lead of the infection prevention and infectious diseases workgroup at Singhealth Polyclinics in Singapore.
But masks are an efficient and effective preventive measure, which is probably why many parents of young children in Singapore still stuck to it even after the island state raised the legal mask-wearing age to six last September. The initial ruling, imposed half a year earlier, required children over two to be masked. (Read more about how face masks reduce transmission.)
For Mimi Zainal, mother to two children aged three and five years old, the change in ruling made no difference. “I prefer the kids to wear masks… it gives me a peace of mind to know they are more protected,” she says.
The children struggled with wearing masks at first, Zainal admits, but she and her husband “hyped it up” into a fun activity that the family would do together before heading out. She bought a variety of patterns – astronauts, unicorns, and other colourful prints – for the children to choose from. Within a matter of weeks, the kids got used to their masks, she says.
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