Advice on the Use of Masks for Children in the Community – COVID-19

MINISTRY OF HEALTH WELLNESS AND THE ENVIRONMENT
Advice on the use of masks for children in the community in the context of COVID-19
September 3rd 2020

Background
Antigua and Barbuda saw its first case of COVID-19 in March 2020. In order to control the
outbreak, the government of Antigua and Barbuda implemented several public health
measures such as the wearing of facemasks, social and physical distancing and handwashing.
Compliance with all these measures including physical distancing, hand hygiene, respiratory
etiquette and adequate ventilation in indoor settings is essential for reducing the spread of
SARS-CoV-2, the virus that causes COVID-19.

Purpose of the document
This document provides guidance to decision makers to inform policy on the use of masks for
children in the context of the COVID-19 pandemic. It does not address the use of masks for
adults working with children or parents/guardians or the use of masks for children in healthcare settings.

These guidelines were adapted for Antigua and Barbuda from information from the World
Health Organization. They are based on Antigua and Barbuda’s Maternal Child and Adolescent
Health Committee’s (MCAHC) Consensus on the Advice the Use of Masks in Children. This
interim guidance will be revised and updated as new evidence emerges.

This document provides specific considerations for the use of non-medical masks, also known
as fabric masks, by children as a means for source control in the context of the current COVID19 pandemic.

For the purposes of this guidance, children are defined as anyone below the age of 18 years.
Advice is outlined for the four following specific age groups.

• Children under two years of age.
• Children between two to five years of age
• Children between five and 11 years of age
• Children between 12 and 18 years of age

Specific Recommendations
1. Children under two years of age

Children under 2 years of age should not wear masks.

2. Children between two to five years of age

Children ages 2-5 years should not wear masks for source control1. This advice is motivated by

a “do no harm” approach and considers:
a) childhood developmental milestones;
b) compliance challenges and;
c) autonomy required to use a mask properly.

Mask wearing in this age group may be required in special circumstances. If these
circumstances require mask wearing is expected for an extended period of time, appropriate
and consistent supervision, including direct line of sight supervision by a competent adult is
needed. This is both to ensure correct use of the mask and to prevent any potential harm
associated with mask wearing to the child.

Special circumstances include:

a) Primary school entry at 5 years, where there may be mixed age groups for example
5- and 6-year olds in a bubble where the 6-year olds are required to wear masks.
Five-year-old who are mixing with six-year olds will be required to wear masks.
b) The presence of vulnerable persons.
c) Other medical and public health advice (medical documentation may be required).

The following public health and social measures should be prioritized to minimize the risk of
SARS-CoV-2 transmission for children five years of age and under who are not required to
wear face masks.

a) Maintaining physical distance of at least 3 feet (1 meter) where feasible. (The consensus
of MCAHC is physical distance of 6 feet or 2 meters if no masks are in use)
b) Educating children to perform frequent hand hygiene
c) Limiting the size of school classes
d) Keeping the integrity of a class “bubble”
e) Ensuring good cross ventilation or outdoor activities when possible.

____________________
1 Source control is a strategy for reducing disease transmission by blocking respiratory
secretions produced through speaking, coughing, or sneezing.

3. Children between six and 11 years of age

Children between the ages if six and 11 years of age should wear face masks. However, a riskbased approach however should also be applied to the decision to use of a mask. This approach
should take into consideration:

a. The child’s capacity to comply with the appropriate use of masks and availability
of appropriate adult supervision
b. Potential impact of mask wearing on learning and psychosocial development
c. Children with disabilities or with underlying diseases

4. Children between 12 and 18 years of age

For children and adolescents 12 years and older, the MCAHC agrees that mask wearing is
required in this group and while Antigua and Barbuda’s national mask guidelines for adults can
be applied in this age category, a risk-based approach should also be applied to the decision to
use of a mask. This approach should take into consideration:

a. The child’s capacity to comply with the appropriate use of masks and availability
of appropriate adult supervision.
b. Potential impact of mask wearing on learning and psychosocial development.
c. Children with disabilities or with underlying diseases.

Special Notes
a. Masks should fit properly (completely covers mouth and nose) and comfortably.
b. Cloth masks made of cotton are more comfortable in the tropical climate, than
those of polyester.
c. Persons with asthma are at a higher risk for respiratory complications from SARSCoV-2 and should be encouraged to use a mask unless there is severe
respiratory disease or complications from the use of a mask.
d. Any medical contra-indication for mask use (includes severe asthma, attention
deficit hyperactivity disorder (ADHD) etc.) must be accompanied by medical
certification/documentation.
e. Special consideration to wear face shields only may be given to students with an
accompanying medical documentation but six (6) feet physical distance is to be
maintained. Face shields should not be used as a replacement for masks.
f. The use of a medical mask for immunocompromised children or children with
certain other diseases (e.g. cancer) is usually recommended but should be
assessed in consultation with the child’s medical provider.
g. In all age groups, measures should be put in place to mitigate exclusion,
stigmatization or bullying for students who are “different”.

Mask Breaks
The MOHWE agrees that mask breaks may be helpful and support the statement in the Back to
School Protocol for the Ministry of Education Science and Technology (MoEST).

As needed, throughout the day, teachers should allow periods for “mask breaks”, that is,
periods where children can remove their masks at safe distances.
Schools should structure times for multiple “mask breaks”.

• Mask breaks for 10 minutes at least 3 times during the school day, may help
students to better comply with wearing the mask

• More frequent mask breaks may be permitted for students who are having
difficulty with keeping on their mask.

• Everyone should immediately wash/sanitise hands before replacing their masks
or re-entering their classes. Wet masks should be changed as soon as possible as
it makes breathing difficult and promote the growth of micro-organisms.

• Mask breaks should only be permitted if the children are:
o Adequately spaced at ideally six (6) feet apart
o Outdoor for recess in small supervised groups
o Eating/drinking
o Engaged in non-contact sports, games and skill building tasks that are
required for curriculum purposes while maintaining six (6) feet distancing.
Kickball and running with enough space are generally safe. Contact sports
at this time are prohibited until such times that the requisite protocols are
developed and approved by Ministry of Health.

Special Note:
Reduced physical activity in children is linked to increased childhood overweight
and obesity as well as negative impact on their mental health. Children should
be permitted where possible to engage in physical activity in school.

Additional Considerations for Children with Disabilities
Children with developmental disorders or disabilities may face additional barriers, limitations
and risks and therefore should be given alternative options to mask wearing, such as face
shields (see above). Policies on masks should be adapted for children with disabilities based on
social, cultural and environmental considerations.

Some children with disabilities require close physical contact with therapists, educators or
social workers. In this context, it is critical that all care providers adopt key infection prevention
and control (IPC) measures, including wearing masks, and that settings are adapted to
strengthen IPC.

The wearing of masks by children with hearing loss or auditory problems may present learning
barriers and further challenges, exacerbated by the need to adhere to the recommended
physical distancing. These children may miss learning opportunities because of the degraded
speech signal stemming from mask wearing, the elimination of lipreading and speaker
expressions and physical distancing. Adapted masks to allow lipreading (e.g. clear masks) or use
of face shields (see above) may be explored as an alternative to fabric masks in these situations.

Monitoring and Evaluation
The COVID-19 situation is very dynamic. The MOHWE will continue to work the MoEST to
monitor the use of face masks in school children. We should look specifically at the impact on
our children’s health, including mental health; reduction in transmission of SARS-CoV-2;
motivators and barriers to mask wearing; and secondary impacts on a child’s development
learning, attendance in school, ability to express him/herself or access school; and impact on
children with developmental delays, health conditions, disabilities or other vulnerabilities.

Data will be used to inform strategies on communication; training and support to teachers,
educators, and parents; engagement activities for children; and distribution of materials that
empower children to use masks appropriately.