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

This survey study assesses whether child masking policies are associated with COVID-19–related childcare program closures.


Introduction
The COVID-19 pandemic and resulting childcare closures have left many parents and guardians struggling to find care for their children while continuing to work, leading to adverse mental health and financial outcomes for families. 1 Thus, keeping childcare programs open safely is of paramount importance. Although exposure to childcare early in the pandemic demonstrated no increased risk of contracting COVID-19, 2 the highly contagious B.1.617.2 (Delta) variant has increased community prevalence, and COVID-19 outbreaks in childcare and among younger children are now well described. [3][4][5] Furthermore, the attack rate for the B.1.1.7 (Alpha) variant, another highly contagious strain, is similar for both children and adults during childcare outbreaks. 4 Face masks reduce SARS-CoV-2 respiratory droplet transmission in the community and high-risk environments. 6,7 In kindergarten through 12th grade schools, masks are part of successful risk mitigation bundles that facilitate a safe return to in-person education. [8][9][10][11] Studies 8,9 suggest that with strict masking policies social distancing can be safely reduced from 6 to 3 feet. However, child masking has not been studied in childcare, where children are typically younger than 5 years, social distancing is challenging, and adherence to masking is less than in older children. 12 This gap in science is particularly problematic given current public debate regarding the benefits and risks of masking younger children not yet eligible for vaccination. We hypothesized that child masking, regardless of social distancing practices, is associated with reduced risk of a childcare program closing because of COVID-19 cases in either staff or children.

Methods
We conducted a 1-year, prospective, longitudinal survey study of childcare professionals throughout the US and territories between May 22 to June 8, 2020 (baseline), and May 26 to June 23,2021 (follow-up). 2,13 Survey questions used for this analysis are found in the eAppendix in the Supplement. Data were deidentified before analysis, and the study was determined to be exempt by the institutional review board of the Yale School of Medicine. This study followed the American Association for Public Opinion Research (AAPOR) reporting guideline.
Baseline data were collected via Qualtrics survey from 19 114 participants actively providing childcare from May 22 to June 8, 2020. The participants were identified through various childcare professional national databases and state childcare professional registries that consented to participate in a follow-up survey and collected all the required information at baseline, so that we could perform data analysis for this study. These national databases and state registries are described in detail in an earlier study. 2 Of these childcare professionals, 16 630 consented to being contacted for a follow-up survey, with 7716 (46.4%) responding to the follow-up survey ( Figure). Reasons for the lack of response included invalid email address (181 [1.1%]), duplicate emails (144 [0.9%]), and the email bouncing back because it was no longer on the system server (236 [1.4%]). The analysis sample was 6654 of responders who self-identified as childcare professionals, consented to participate, and provided follow-up data regarding COVID-19-related closures (Figure; Table 1).

Variables
The exposure variable was initially defined as all children (2 years and older) wearing a mask or facial covering at baseline (April 2020). We also assessed child masking during the past 15 days the program was open before survey completion at both baseline and follow-up 1 year later (see survey questions in the eAppendix in the Supplement). Covariates included other various infection mitigation strategies reported at baseline by childcare professionals to prevent transmission of COVID-19 (no = 0, yes = 1), including temperature and COVID-19 symptom screening, outside drop-off and pickup, and maintaining a distance of 6 ft between child seats and cots (6-ft distancing) ( Table 2). These variables represent self-reported and observed practices as reported by the childcare professionals. The outcome was whether the childcare professional reported at follow-up

Statistical Analysis
We used a generalized linear model (log-binomial) with robust SEs to estimate risk ratios for the association among COVID-19 closure, child masking, and 6-ft distancing, controlling for other risk mitigation strategies and program and community characteristics presented in Table 2 and Table 3.
We also tested in a separate model whether continued child masking and 6-ft distancing affected associations by coding the mitigation strategies in Table 2 as yes (1) if reported at both baseline and follow-up and no (0) if not. This method represents programs that reported practicing these activities at both time points, a proxy for continued practices with an assumption of no intermittent breaks, compared with programs that reported practicing mitigation strategies at any one time point or not at all. We also ran separate models with combined adult and child masking variable as the exposure variable coded as a categorical variable of 0 to 3, with 0 representing no masking, 1 representing adult masked but no child masking, 2 representing child masked but no adult masking, and 3 representing both masked. A 2-sided P < .05 was considered to be statistically significant. years or older). The characteristics of the childcare programs and demographic characteristics of the respondents are shown in Table 1. Childcare programs of respondents did not differ significantly from nonrespondents on baseline county-level COVID-19 death rates or on whether the program ever closed because of COVID-19 before baseline. Respondents were more likely home based (paid childcare provided in a home) rather than center based (paid childcare provided in a childcare center) and in counties with higher mean annual household income and less likely to endorse masking at baseline, although the Cramér V, an effect size measure for χ 2 tests of variable associations, was in the negligible range (<|0.10| for each). 15 At follow-up, respondents reported that 2839 programs (42.7%) had closed because of COVID-19 (Table 3). Child masking increased from 572 programs (8.6%) at baseline to 2060 programs (32.7%) 1 year later, with 408 programs (6.1%) masking at both time points (Table 2). Changes in adherence to other practiced mitigation measures during the study period are described in Table 2.   In multivariable analysis (

Discussion
This survey study of a large prospective cohort of childcare professionals found that early adoption of child masking in May to June 2020 was associated with a 13% reduction in COVID-19-related childcare program closures during the 1-year follow-up. Furthermore, continued endorsement of child masking at both the May to June 2020 and May to June 2021 timepoints was associated with a 14% reduction in COVID-19 childcare closures when controlling for other risk mitigation strategies, such as social distancing, symptom screening, outside drop-off, and temperature monitoring.
The benefits of masking in preventing COVID-19 spread within kindergarten through 12th grade classrooms are well described. [8][9][10][11] Masks can be worn safely by young children without compromising respiratory function. 16 In other studies, 17,18 childhood infection with other respiratory viruses decreased and asthma symptoms were not reported when masks were worn by preschool children  along with other risk mitigation strategies. One reason for this may be that those who wear masks display reduced face touching behavior, a known risk mechanism for respiratory viral transmission. 19 The federally funded Head Start program requires masks for staff and children as part of a broader COVID-19 prevention plan, a strategy endorsed by the Centers for Disease Control and Prevention and the American Academy of Pediatrics. 20,21 Most childcare professionals who affirmed child masking also reported their program engaged in multiple other risk mitigation behaviors consistent with this comprehensive approach.

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Concerns have been raised regarding the potential for social and developmental delays when younger children wear a face mask for prolonged periods because of lack of recognition of emotional cues. 22,23 Notably, these are point-in-time studies, and how quickly children adapt and recognize other emotional cues, such as body language, is not known. Evidence suggests that school-age children can identify most emotions in masked faces. 22,24 Two-year-old children recognize spoken words better through an opaque mask compared with a clear face shield, suggesting verbal communication to infants is not harmed by face masks. 25 We are unaware of published research on the long-term effects, if any, on intermittent masking. For medical care, most children 4 to 10 years of age did not prefer unmasked health care professionals to masked health care professionals and did not fear health care professionals with masks. 26 Early adopters of masking may represent a group of highly vigilant programs that emphasized COVID-19 prevention. Surprisingly, we did not find an association between adult masking alone and the prevention of COVID-19-related childcare closures. One possible explanation is that programs that did not endorse strict masking policies were less concerned about COVID-19 in general and less likely to close when there were COVID-19 exposures or cases in the program.
The percentage of programs reporting child masking increased to 33% during the follow-up survey compared with 9% at baseline. However, we did not ascertain specifically when in the study period masking was initiated and whether it was because of a COVID-19 case or as a preemptive measure to prevent closure. Therefore, we did not examine an association between COVID-19 related closures and child masking only in the follow-up survey.

Strengths and Limitations
This study has several strengths. The main strength is the prospective data collection from a large national cohort of childcare professionals, which increases the generalizability of our findings. The retention rate at 1 year was high. In addition, the collected data reflected self-reported practices in childcare settings rather than policies that may or may not be adhered to.
The study also has some limitations, including potential respondent bias because childcare professionals were asked about behaviors that were not independently confirmed. Similarly, programs that report mitigation practices at both baseline and follow-up may not have been continuously adhering to these practices, resulting in a biased estimate. We did not ask specifically about childcare program policies regarding masking or criteria for closure. Thus, we do not know what percentage of respondents were adhering to employer guidelines. Different programs may have varied criteria for closure (eg, any COVID-19 exposure in the program vs documented withinprogram transmission). Our data cannot differentiate between closures that were due to withincenter transmission and closures due to imported COVID-19 infection. Both adult and child behavior outside childcare, such as play dates and other social gatherings where child or adult masking are not enforced, also influence COVID-19 cases in congregate settings and therefore the probability of program closure. 27 Alternatively, adults and children who masked may have engaged in other preventive measures that were not controlled for, such as avoiding travel, reducing the likelihood of importing COVID-19 cases into the childcare program.
A previous study 2 documenting low SARS-CoV-2 transmission in childcare programs was conducted before the emergence of the Delta variant, which can spread rapidly in elementary school children. 5 The Delta variant was not the predominant strain circulating in the US during this study period, emerging later. Therefore, our results may underappreciate the value of masking because the SARS-CoV-2 strains circulating during the study period were likely less contagious than the Delta variant.

Conclusions
Despite these limitations, this large survey study of childcare professionals suggests that masking

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Association of Child Masking With COVID-19 Childcare Program Closures