Child Care in the Time of Coronavirus Disease-19: A Period of Challenge and Opportunity
2020; Elsevier BV; Volume: 225; Linguagem: Inglês
10.1016/j.jpeds.2020.07.042
ISSN1097-6833
AutoresAndrew N. Hashikawa, Jill M. Sells, Peter M. DeJonge, Abbey Alkon, Emily T. Martin, Timothy R. Shope,
Tópico(s)Youth Substance Use and School Attendance
ResumoThe early care and education of young children, more commonly known as child care, is a ubiquitous experience in the US across geographies and socioeconomic levels. Nationally, more than 12 million children—or nearly two-thirds of children under 5 years of age—regularly participate in out-of-home care, making early care and education a $47.2 billion industry with a workforce of more than 1.5 million child care providers.1Committee for Economic Development Child care in state economies 2019 update.www.ced.org/assets/reports/childcareimpact/181104%20CCSE%20Report%20Jan30.pdfGoogle Scholar, 2Kennedy L.B. Mayshak K. Say hello to that new spin studio and goodbye to your child care. The New York Times, 2020Google Scholar, 3US Census BureauWho's minding the kids? Child care arrangements.http://www.census.gov/prod/2013pubs/p70-135.pdfGoogle Scholar Early care and education involves children from birth through kindergarten entry, a time when organized, group care, including child care centers, family child care homes, preschool, and Head Start programs represent the majority of child care arrangements.1Committee for Economic Development Child care in state economies 2019 update.www.ced.org/assets/reports/childcareimpact/181104%20CCSE%20Report%20Jan30.pdfGoogle Scholar Unlike other major Western countries, the US lacks a national child care system with a comprehensive centralized mechanism for policymaking or coordinated funding.4Zigler E. Tragedy of child care in America. Yale University Press, 2009Crossref Google Scholar Therefore, early care and education in the US is fragmented, leading to substantial variability in the availability, cost, and quality of child care.4Zigler E. Tragedy of child care in America. Yale University Press, 2009Crossref Google Scholar This piecemeal system has been severely challenged by the global pandemic associated with the severe acute respiratory syndrome coronavirus 2019 (SARS-CoV-2), owing to both preexisting structural and financial problems of the early care and education system, as well as the unique epidemiology of coronavirus disease 2019 (COVID-19) disease in children. Preexisting shortcomings of the US early care and education system worsened during the pandemic, presenting novel challenges for early care and education programs related to the COVID-19 pandemic. We offer recommendations for improving health in early care and education programs at this time. Before the COVID-19 pandemic, early care and education access was a significant challenge for many families because of its expense and limited supply.5Center for American Progress Child care deserts.https://childcaredeserts.org/Google Scholar,6Child Care Aware The US and the high price of child care: an examination of a broken system.www.childcareaware.org/our-issues/research/the-us-and-the-high-price-of-child-care-2019/Date: 2019Google Scholar US early care and education programs have high operating costs and, unlike public schools, receive minimal federal or state subsidies.2Kennedy L.B. Mayshak K. Say hello to that new spin studio and goodbye to your child care. The New York Times, 2020Google Scholar,4Zigler E. Tragedy of child care in America. Yale University Press, 2009Crossref Google Scholar,6Child Care Aware The US and the high price of child care: an examination of a broken system.www.childcareaware.org/our-issues/research/the-us-and-the-high-price-of-child-care-2019/Date: 2019Google Scholar Some programs, such as Head Start and military-sponsored programs, receive federal funding, but these represent only a small fraction of early care and education arrangements.1Committee for Economic Development Child care in state economies 2019 update.www.ced.org/assets/reports/childcareimpact/181104%20CCSE%20Report%20Jan30.pdfGoogle Scholar The high operating costs of early care and education are passed onto families in the form of tuition and can represent a substantial proportion of a family's income; in some states, the price approaches or exceeds in-state college tuition.6Child Care Aware The US and the high price of child care: an examination of a broken system.www.childcareaware.org/our-issues/research/the-us-and-the-high-price-of-child-care-2019/Date: 2019Google Scholar High-quality early care and education has become cost prohibitive to most poor and minority families.4Zigler E. Tragedy of child care in America. Yale University Press, 2009Crossref Google Scholar,6Child Care Aware The US and the high price of child care: an examination of a broken system.www.childcareaware.org/our-issues/research/the-us-and-the-high-price-of-child-care-2019/Date: 2019Google Scholar The federal government has provided some funding to states that is intended to subsidize early care and education costs for low-income families (eg, Child Care and Development Fund, Temporary Assistance for Needy Families, and the Social Services Block Grant), but these funds cover only 30% of total child care expenditures nationally.1Committee for Economic Development Child care in state economies 2019 update.www.ced.org/assets/reports/childcareimpact/181104%20CCSE%20Report%20Jan30.pdfGoogle Scholar Similarly, federal tax credits, which only apply to middle-class families, average 10% or less of the cost of full-time child care.1Committee for Economic Development Child care in state economies 2019 update.www.ced.org/assets/reports/childcareimpact/181104%20CCSE%20Report%20Jan30.pdfGoogle Scholar Furthermore, more than 50% of the US population lives in child care "deserts," or census tract areas that either completely lack early care and education services or only have one-third of the licensed child care capacity needed by families.5Center for American Progress Child care deserts.https://childcaredeserts.org/Google Scholar Early care and education deserts are more frequently found in rural, low-income areas, and also are associated with a high proportion of minority residents.5Center for American Progress Child care deserts.https://childcaredeserts.org/Google Scholar Even in locations with sufficient early care and education capacity, many parents report having significant difficulty finding backup child care when their child is sick and cannot attend their regular early care and education program.7Hashikawa A.N. Brousseau D.C. Singer D.C. Gebremariam A. Davis M.M. Emergency department and urgent care for children excluded from child care.Pediatrics. 2014; 134: e120-e127Crossref PubMed Scopus (16) Google Scholar Parents often rely on nonparental relatives such as the child's grandparents for emergency child care; now, the pandemic has limited this backup option because of the concern for the spread of COVID-19 to more vulnerable, high-risk family members.8Bipartisan Policy Center Nationwide SurveyChild care in the time of coronavirus.https://bipartisanpolicy.org/blog/nationwide-survey-child-care-in-the-time-of-coronavirus/Google Scholar The pandemic has impacted the availability of early care and education, both in the early months of the pandemic and likely into the future as well. In most states, social distancing policies shuttered nonessential businesses temporarily, but there was a variety of responses related to early care and education programs. Some states closed all organized early care and education programs, others allowed exemptions for programs that cared for children of essential workers, and some did not close any programs. Early care and education program closings varied so markedly from state to state that dashboards were created to track different state closings.9Child Care Aware State by state resources - statewide child care status.www.childcareaware.org/resources/map/Google Scholar During COVID-19, as businesses closed and parents were furloughed or worked from home, demand for early care and education from these parents decreased, decreasing attendance and decreasing revenue to early care and education programs, resulting in further closures of programs for financial reasons. An estimated 60% of early care and education programs and 96% of Head Start programs were closed (S. Shuman, Senior Training and Technical Assistance Associate, National Center on Early Childhood Health and Wellness Development Center, written communication, June 30, 2020), during the first 2 months of the pandemic.8Bipartisan Policy Center Nationwide SurveyChild care in the time of coronavirus.https://bipartisanpolicy.org/blog/nationwide-survey-child-care-in-the-time-of-coronavirus/Google Scholar A May 2020 national survey of 163 child care resource and referral (CCR&R) agencies from 41 states found that 77% of CCR&R agencies were planning to assist child care programs in reopening and 37% of CCR&R were administering federal funding directly to early care and education programs.10Child Care Aware CCR&R response to the coronavirus.https://info.childcareaware.org/hubfs/ccrr-survey-pdf.pdfGoogle Scholar The closure of early care and education programs caused problems for essential workers (eg, health care workers, first responders, transit workers, grocers). A nationally representative survey of parents found that more than one-third of respondents found it "very difficult" to find child care, nearly double that from the same period 6 months prior, and particularly remarkable considering simultaneously decreased demand because of historically high unemployment.8Bipartisan Policy Center Nationwide SurveyChild care in the time of coronavirus.https://bipartisanpolicy.org/blog/nationwide-survey-child-care-in-the-time-of-coronavirus/Google Scholar Only 22% of essential workers were able to continue their previous early care and education arrangements during the pandemic and parents were nearly twice as likely to report difficulties finding quality early care and education programs within their budget.8Bipartisan Policy Center Nationwide SurveyChild care in the time of coronavirus.https://bipartisanpolicy.org/blog/nationwide-survey-child-care-in-the-time-of-coronavirus/Google Scholar Many low-income essential workers were without paid leave, did not have an available family caregiver, or also were less likely than high-income parents to be able to work remotely.8Bipartisan Policy Center Nationwide SurveyChild care in the time of coronavirus.https://bipartisanpolicy.org/blog/nationwide-survey-child-care-in-the-time-of-coronavirus/Google Scholar However, even among parents who could work from home, a national survey reported that 43% still required child care.8Bipartisan Policy Center Nationwide SurveyChild care in the time of coronavirus.https://bipartisanpolicy.org/blog/nationwide-survey-child-care-in-the-time-of-coronavirus/Google Scholar Typically, the majority of revenue for early care and education programs is derived from tuition fees, and 80% of child care program expenses are related to payroll; most experts view this as unsustainable.6Child Care Aware The US and the high price of child care: an examination of a broken system.www.childcareaware.org/our-issues/research/the-us-and-the-high-price-of-child-care-2019/Date: 2019Google Scholar Indeed, previous regional disasters and societal upheaval consistently have demonstrated the fragility of the early care and education infrastructure.11Save the Children. Child care - an essential service for disaster recovery.www.savethechildren.org/content/dam/usa/reports/emergency-prep/GRGS-BRIEF-2007.PDFGoogle Scholar,12Swaby A. Without recovery funds, more than 50 Texas day cares close after Harvey.27. The Texas Tribune, 2017Google Scholar For example, most early care and education programs are a low-margin business and have limited access to recovery funds. Therefore, if they are closed for relatively brief periods in excess of several weeks, they cannot meet payroll or pay rent, often resulting in permanent closure.12Swaby A. Without recovery funds, more than 50 Texas day cares close after Harvey.27. The Texas Tribune, 2017Google Scholar Subsequently, the lack of available early care and education programs for families after disasters significantly affects recovery efforts by keeping families from working and businesses from rebounding economically.11Save the Children. Child care - an essential service for disaster recovery.www.savethechildren.org/content/dam/usa/reports/emergency-prep/GRGS-BRIEF-2007.PDFGoogle Scholar,13Save the Children. Disaster report card.www.savethechildren.org/us/what-we-do/us-programs/disaster-relief-in-america/family-emergency-preparedness-plan/disaster-report-cardGoogle Scholar Although early care and education is considered a critical service by the Federal Emergency Management Agency for regional recovery, early care and education programs are underprepared for emergencies and are usually overlooked during disaster recovery planning.11Save the Children. Child care - an essential service for disaster recovery.www.savethechildren.org/content/dam/usa/reports/emergency-prep/GRGS-BRIEF-2007.PDFGoogle Scholar,13Save the Children. Disaster report card.www.savethechildren.org/us/what-we-do/us-programs/disaster-relief-in-america/family-emergency-preparedness-plan/disaster-report-cardGoogle Scholar,14FEMA Critical components of a child's world.https://emilms.fema.gov/IS0366a/lesson3/L3_print.htmGoogle Scholar The COVID-19 pandemic has placed substantial financial strains on the industry, with smaller early care and education programs vulnerable to permanent financial collapse, and very little direct federal or state public financial support. One national survey conducted by the National Association for the Education of Young Children in March 2020 found that many early care and education owners questioned the future viability of the early care and education industry.15National Association for the Education of Young ChildrenChild care in crisis understanding the effects of the coronavirus pandemic.www.naeyc.org/sites/default/files/globally-shared/downloads/PDFs/our-work/public-policy-advocacy/effects_of_coronavirus_on_child_care.final.pdfGoogle Scholar The survey revealed that 50% of early care and education programs were losing income because families were unable to pay, with another 25% losing additional income because states reimbursed providers based on attendance rather than enrollment for low-income families receiving child care subsidies, and thus these payments decreased as well when children stayed home.15National Association for the Education of Young ChildrenChild care in crisis understanding the effects of the coronavirus pandemic.www.naeyc.org/sites/default/files/globally-shared/downloads/PDFs/our-work/public-policy-advocacy/effects_of_coronavirus_on_child_care.final.pdfGoogle Scholar This is dire news for a workforce that is overwhelmingly female, minority (40%), significantly underpaid (double the proportion of workers living below the poverty line compared with other industries), and lacking health insurance despite having many underlying chronic health conditions.6Child Care Aware The US and the high price of child care: an examination of a broken system.www.childcareaware.org/our-issues/research/the-us-and-the-high-price-of-child-care-2019/Date: 2019Google Scholar,16Linnan L. Arandia G. Bateman L.A. Vaughn A. Smith N. Ward D. The Health and working conditions of women employed in child care.Int J Environ Res Public Health. 2017; 14Crossref Scopus (61) Google Scholar CCR&R agencies have reported that the attrition of the child care workforce is among the top concerns for early care and education programs during the pandemic.10Child Care Aware CCR&R response to the coronavirus.https://info.childcareaware.org/hubfs/ccrr-survey-pdf.pdfGoogle Scholar The federal government has met some of the immediate early care and education needs during the pandemic, but has fallen short in other areas. Realizing the early care and education system's importance to the economic infrastructure, Congress included specific provisions for the early care and education sector when passing the $2 trillion dollar Coronavirus Aid, Relief, and Economic Security Act. The Coronavirus Aid, Relief, and Economic Security Act included $3.5 billion in discretionary funding to states to help support early care and education through payment assistance to programs experiencing decreased enrollment, emergency child care for essential workers, financial assistance to parents working in critical sectors, and funding for purchasing supplies to stay open or reopen.17Administration for Children and FamiliesSummary of child care provisions of Coronavirus Aid, Relief, and Economic Security Act or "CARES Act".www.acf.hhs.gov/occ/resource/summary-of-child-care-provisions-of-cares-actGoogle Scholar Currently, most early care and education providers, with little cash reserves and high overhead costs, are unsure if they can remain in business without further financial support from the state or federal government.15National Association for the Education of Young ChildrenChild care in crisis understanding the effects of the coronavirus pandemic.www.naeyc.org/sites/default/files/globally-shared/downloads/PDFs/our-work/public-policy-advocacy/effects_of_coronavirus_on_child_care.final.pdfGoogle Scholar Other additional legislation to financially support the early care and education industry is currently pending in Congress.18116th Congress H.R. 7027, Child Care Is Essential Act, Bill Profile. U.S. Government Publishing Office, Washington D.CMay 27, 2020Google Scholar The early care and education system also was not included when the Department of Homeland Security identified 16 groups of critical infrastructure sectors during the COVID-19 pandemic.19Cybersecurity and Infrastructure Security Agency Identifying critical infrastructure during COVID-19.www.cisa.gov/identifying-critical-infrastructure-during-covid-19Google Scholar The designation as critical essential infrastructure workforce is a way to assist states and local governments in prioritizing accommodations for employees critical to operations so they can continue to work during the pandemic.19Cybersecurity and Infrastructure Security Agency Identifying critical infrastructure during COVID-19.www.cisa.gov/identifying-critical-infrastructure-during-covid-19Google Scholar There are no comprehensive federal regulations for the safe and healthy operation of early care and education programs, other than federally funded Head Start and military programs. Instead, regulations are developed at the state level, resulting in a high degree of national variability in the health and safety requirements for licensed programs. Even within states, early care and education practices and policies vary between programs, and a significant proportion of early care and education in the US is unlicensed and unregulated.4Zigler E. Tragedy of child care in America. Yale University Press, 2009Crossref Google Scholar Across states and local jurisdictions, early care and education agencies and programs have variable access to support from health professionals such as child care health consultants (CCHC) to discern needs, inform the development of standards for daily operation, disseminate these standards, and support implementation. These standards include adequately detailed and updated emergency, disaster, and pandemic plans, which most licensed early care and education businesses lack despite being required for licensing in many states.10Child Care Aware CCR&R response to the coronavirus.https://info.childcareaware.org/hubfs/ccrr-survey-pdf.pdfGoogle Scholar,20Chang M.T. Bradin S. Hashikawa A.N. Disaster Preparedness Among Michigan's Licensed Child Care Programs.Pediatr Emerg Care. 2018; 34: 349-356Crossref PubMed Scopus (6) Google Scholar,21Shope T.R. Walker B.H. Aird L.D. Southward L. McCown J.S. Martin J.M. Pandemic influenza preparedness among child care center directors in 2008 and 2016.Pediatrics. 2017; 139: e20163690Crossref PubMed Scopus (14) Google Scholar There has not been a nationally coordinated effort to develop, disseminate, and implement effective, adequately detailed guidance for the early care and education system during the COVID-19 pandemic. Initial Centers for Disease Control and Prevention (CDC) recommendations offered guidance for programs that remained open to care for children of essential workers.22Centers for Disease Control and Prevention. Interim guidance for administrators of US K-12 schools and child care programs - plan, prepare, and respond to coronavirus disease 2019 (COVID-19).http://www.cdc.gov/coronavirus/2019-ncov/community/schools-childcare/guidance-for-schools.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fspecific-groups%2Fguidance-for-schools.htmlGoogle Scholar This guidance was replaced by advice for programs "that remain open" and was complemented by a protocol offered to commercial businesses regarding social distancing, cleaning, and screening as they reopen.23Centers for Disease Control and Prevention (CDC)Activities and initiatives supporting the COVID-19 response and the President's plan for opening America up again. Atlanta: CDC.2020Google Scholar,24Centers for Disease Control and Prevention (CDC)Guidance for child care programs that remain open.www.cdc.gov/coronavirus/2019-ncov/community/schools-childcare/guidance-for-childcare.htmlGoogle Scholar These guidelines remain largely insufficient for the day-to-day operational needs of most early care and education programs. National standards for early care and education—including those related to emergencies and infection control—exist for health and safety in child care, which are published in Caring for Our Children by the American Academy of Pediatrics, the American Public Health Association, and the National Resource Center for Health and Safety in Child Care and Early Education.25American Academy of PediatricsAmerican Public Health Association, National Resource Center for Health and Safety in Child Care and Early Education. CFOC standards online database.https://nrckids.org/CFOC/Google Scholar However, there is no mechanism to rapidly modify, update, and disseminate these standards to meet the needs of the COVID-19 pandemic. Existing Caring for Our Children standards do not address the new concerns expressed by early care and education workers during the pandemic, which include determining the risks for early care and education workers, establishing whether physical distancing in young children is feasible and effective, providing more details about cleaning and disinfecting, defining new group size requirements, defining the proper use of SARS-CoV-2 screening tests, handling readmission of children with symptoms or positive COVID-19 tests, and establishing guidelines for temperature checks (type of thermometer, fever threshold for exclusion, when to take temperatures after the initial screening).26National Resource Center for Health and Safety in Child Care and Early EducationCOVID-19 questions - CFOC crosswalk. National Resource Center for Health and Safety in Child Care and Early Education, Aurora, CO2020Google Scholar Without federal or other national guidance, each state government and local health department is left to develop their own early care and education health policies. SARS-CoV-2 is not yet well-understood, with a distinct lack of pediatric SARS-CoV-2 epidemiologic studies in group settings to guide policy and practice.27Kelvin A.A. Halperin S. COVID-19 in children: the link in the transmission chain.Lancet Infect Dis. 2020; 20: 633-634Abstract Full Text Full Text PDF PubMed Scopus (188) Google Scholar In part, this is because a large proportion of infected children have asymptomatic or mild COVID-19 clinical courses. Although uncommon, childhood cases of COVID-19 can also be severe. The multisystem inflammatory syndrome in children associated with SARS-CoV-2 infection, which shares some characteristics with Kawasaki disease, has prompted a recent CDC alert.28Levin M. Childhood multisystem inflammatory syndrome - a new challenge in the pandemic.N Engl J Med. 2020; ([Epub ahead of print])Crossref Scopus (155) Google Scholar, 29Feldstein L.R. Rose E.B. Horwitz S.M. Collins J.P. Newhams M.M. Son M.B.F. et al.Multisystem inflammatory syndrome in U.S. children and adolescents.N Engl J Med. 2020; ([Epub ahead of print])Crossref PubMed Scopus (1769) Google Scholar, 30Belhadjer Z. Meot M. Bajolle F. Khraiche D. Legendre A. Abakka S. et al.Acute heart failure in multisystem inflammatory syndrome in children (MIS-C) in the context of global SARS-CoV-2 pandemic.Circulation. 2020; ([Epub ahead of print])Crossref PubMed Scopus (897) Google Scholar, 31Centers for Disease Control and Prevention Health Alert NetworkMultisystem inflammatory syndrome in children (MIS-C) associated with coronavirus disease 2019 (COVID-19) (HAN00432).https://emergency.cdc.gov/han/2020/han00432.aspGoogle Scholar However, because most children with SARS-CoV-2 infection have mild to no symptoms, childhood cases often are detected only through contact tracing related to an adult clinical case.30Belhadjer Z. Meot M. Bajolle F. Khraiche D. Legendre A. Abakka S. et al.Acute heart failure in multisystem inflammatory syndrome in children (MIS-C) in the context of global SARS-CoV-2 pandemic.Circulation. 2020; ([Epub ahead of print])Crossref PubMed Scopus (897) Google Scholar, 31Centers for Disease Control and Prevention Health Alert NetworkMultisystem inflammatory syndrome in children (MIS-C) associated with coronavirus disease 2019 (COVID-19) (HAN00432).https://emergency.cdc.gov/han/2020/han00432.aspGoogle Scholar, 32Isaacs D. Britton P. Howard-Jones A. Kesson A. Khatami A. Marais B. et al.To what extent do children transmit SARS-CoV-2 virus?.J Paediatr Child Health. 2020; 56: 978-979Crossref PubMed Scopus (16) Google Scholar As a result of underdetection in children, the extent to which children may fuel community spread of SARS-CoV-2, as with other respiratory illnesses, is currently unknown.32Isaacs D. Britton P. Howard-Jones A. Kesson A. Khatami A. Marais B. et al.To what extent do children transmit SARS-CoV-2 virus?.J Paediatr Child Health. 2020; 56: 978-979Crossref PubMed Scopus (16) Google Scholar, 33Heavey L. Casey G. Kelly C. Kelly D. McDarby G. No evidence of secondary transmission of COVID-19 from children attending school in Ireland.Euro Surveill. 2020; 25: 2-5Crossref Scopus (174) Google Scholar, 34Gudbjartsson D.F. Helgason A. Jonsson H. Magnusson O.T. Melsted P. Norddahl G.L. et al.Spread of SARS-CoV-2 in the Icelandic population.N Engl J Med. 2020; 382: 2302-2315Crossref PubMed Scopus (866) Google Scholar The recommendations to close early care and education programs and schools, however, were derived from epidemiologic transmission studies of influenza, which has disproportionately higher transmission rates and clinical disease in young children.33Heavey L. Casey G. Kelly C. Kelly D. McDarby G. No evidence of secondary transmission of COVID-19 from children attending school in Ireland.Euro Surveill. 2020; 25: 2-5Crossref Scopus (174) Google Scholar,35NPR After reopening schools, Israel orders them to shut if COVID-19 cases are discovered.www.npr.org/sections/coronavirus-live-updates/2020/06/03/868507524/israel-orders-schools-to-close-when-covid-19-cases-are-discoveredGoogle Scholar At present, SARS-CoV-2, compared with influenza, seems to infect fewer and cause milder clinical disease in young children, and have higher transmissibility among adults.30Belhadjer Z. Meot M. Bajolle F. Khraiche D. Legendre A. Abakka S. et al.Acute heart failure in multisystem inflammatory syndrome in children (MIS-C) in the context of global SARS-CoV-2 pandemic.Circulation. 2020; ([Epub ahead of print])Crossref PubMed Scopus (897) Google Scholar, 31Centers for Disease Control and Prevention Health Alert NetworkMultisystem inflammatory syndrome in children (MIS-C) associated with coronavirus disease 2019 (COVID-19) (HAN00432).https://emergency.cdc.gov/han/2020/han00432.aspGoogle Scholar, 32Isaacs D. Britton P. Howard-Jones A. Kesson A. Khatami A. Marais B. et al.To what extent do children transmit SARS-CoV-2 virus?.J Paediatr Child Health. 2020; 56: 978-979Crossref PubMed Scopus (16) Google Scholar,36OXNER R. More than 300 children in Texas day cares have caught COVID-19, and the numbers are rising. The Texas Tribune, 2020Google Scholar SARS-CoV-2 surveillance data in group settings are not yet available, but neither are published reports of widespread child-to-child transmission of COVID-19 in early care and education or school settings, suggesting transmission in these settings is either uncommon or unrecognized owing to mild or asymptomatic infection.32Isaacs D. Britton P. Howard-Jones A. Kesson A. Khatami A. Marais B. et al.To what extent do children transmit SARS-CoV-2 virus?.J Paediatr Child Health. 2020; 56: 978-979Crossref PubMed Scopus (16) Google Scholar, 33Heavey L. Casey G. Kelly C. Kelly D. McDarby G. No evidence of secondary transmission of COVID-19 from children attending school in Ireland.Euro Surveill. 2020; 25: 2-5Crossref Scopus (174) Google Scholar, 34Gudbjartsson D.F. Helgason A. Jonsson H. Magnusson O.T. Melsted P. Norddahl G.L. et al.Spread of SARS-CoV-2 in the Icelandic population.N Engl J Med. 2020; 382: 2302-2315Crossref PubMed Scopus (866) Google Scholar However, media reports of COVID-19 outbreaks in schools in Israel and child care centers in Texas require further research to determine the extent of child-to-child transmission from infected adults to children.37Esposito S. Principi N. School closure during the coronavirus disease 2019 (COVID-19) pandemic: an effective intervention at the global level?.JAMA Pediatr. 2020; ([Epub ahead of print])Crossref PubMed Scopus (167) Google Scholar,38American Academy of PediatricsCOVID-19 planning considerations: guidance for school re-entry.https://
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