COVID-19 Back-to-school guidance

During this unprecedented time of the COVID-19 pandemic, many decisions that were previously straightforward have become complex and challenging. Whether or not to send children to school is one such decision, and parents are processing the many factors that influence these difficult decisions.

Many of the patients we serve at Children’s Health℠ have unique medical conditions, are on certain medications that may change their risk of complications in the setting of COVID-19, live with at-risk family members, or have unique living or emotional situations that complicate decisions around returning to school. This situation has led to many concerns and questions about how to handle return to school.

Should I send my child back to school in person?

In order to help provide information, a group of physician specialists at Children’s Health and UT Southwestern collectively addressed these concerns and questions. As a team, we evaluated the various health conditions and medications that potentially impair the immune system and may place a child at higher risk for complications from COVID-19. 

Guidance provided by UT Southwestern physicians

We designated risk categories to enable thoughtful decision-making. Additionally, we identified circumstances that may influence school decisions for certain families and identified helpful resources available to support children during this time to guide decision-making.

Determine your child's risk by program:

There are some medical conditions for which returning to school poses an increased risk. The exact risk is unknown. COVID-19 is a brand new disease and pediatricians are learning more as cases in children increase.

To help guide parents in the decision to send their child with a medical condition back to school, we have categorized various medical conditions as low, moderate and high risk, based on expert consensus opinion. This opinion is subject to change as new medical data regarding risk in children is published in the medical literature, and as our experience in treating COVID-19 increases.

These recommendations will be updated as more information becomes available.

• Demyelinating Disease / Neuroimmunology

  Does my child’s diagnosis place them at increased risk?

  First, for our patients diagnosed with multiple sclerosis, transverse myelitis, acute flaccid myelitis, NMO, ADEM, optic neuritis anti-MOG Antibody associated disorder and autoimmune encephalitis, we have not seen a link between these conditions and complications from SARS-CoV2. While the specific diagnosis does not confer increased risks, any of our patients who have had changes in their lung function due to their neurologic disease, should consult with their pulmonologist as well.

  Absent that issue, we recommend our patients and families take standard precautions (masks in public, social distancing, hand washing, avoiding crowds, etc.). We also have not seen any data to suggest that infection with the coronavirus can consider a relapse of any of these conditions. Below is a table listing the various conditions our clinic focuses on and the relative risk rating to SARS-CoV2.

  Diagnosis	Risk
  Acute Disseminated Encephalomyelitis (ADEM)	Low
  Acute Flaccid Myelitis	Low
  Anti-MOG Ab Associated Disorder	Low
  Autoimmune Encephalitis	Low
  Multiple Sclerosis	Low
  Neuromyelitis Optica Spectrum Disorder	Low
  Optic Neuritis	Low
  Transverse Myelitis	Low

   

  Does my child’s medication place them at increase risk? 

  Relative to the medications we frequently prescribe, we have been tracking available data to determine if the medications increase the risk of complications from the SARS-CoV2 virus, if a person becomes infected. It is important to know that data about this topic is very limited, but the following table outlines the most common immunomodulator prescriptions and the relative risk. 

  We rate the medications as low, moderate or high risk based on available data and our concerns based on how these medications effect the immune system. As mentioned above, these recommendations and categories are subject to change based on new data becoming available. 

  Medication	Brand Names	SARS-CoV2 Complication Risk
  Alemtuzumab	Lemtrada	High
  Cladribine	Mavenclad	Moderate
  Dexamethasone	Decadron	Moderate
  Dimethyl Fumarate/ Diroximel Fumarate	Tecfidera, Vumerity	Low
  Fingolimod	Gilenya	Low
  Glatiramer Acetate	Copaxone, Glatopa	Low
  Interferon Beta	Avonex, Betaseron, Plegridy, Rebif	Low
  IVIG	Gamunex, Privigen, Octagam, Gammagard	Low
  Mycophenolate	Cellcept, Myfortic	Moderate
  Natalizumab	Tysabri	Low
  Ocrelizumab	Ocrevus	High
  Prednisone	Deltasone (and others)	Moderate
  Rituximab	Rituxan	High
  Siponimod	Mayzent	Low
  Teriflunomide	Aubagio	Low

   

  Go to main Demyelinating Program page.

• Diabetes and Endocrinology

  Children and young people with type 1 diabetes appear to be at a low risk of becoming seriously ill from COVID-19. For more in-depth COVID-19 guidance for Diabetes patients, please visit our Diabetes and COVID-19 page.

  Children with the following conditions need to be aware that their underlying conditions carry added risk, especially during times of high COVID numbers in their local communities, and thus should strongly consider remote and virtual learning opportunities as offered by their school districts until local numbers return to lower risk profiles.  

  Based on current data, there is no evidence that the following patients are at increased risk of contracting COVID-19. However, children with the following conditions may be at higher risk of medical complications or severe illness in the case of COVID-19 infection. 

  Diagnosis	Risk
  Adrenal Insufficiency (due to congenital adrenal hyperplasia (CAH), autoimmune Addison’s disease, pituitary disease (secondary adrenal insufficiency) or other causes)	Low-Moderate
  Diabetes Insipidus	Low-Moderate
  Obesity (associated conditions can include type 2 diabetes, poorly controlled hypertension, etc.)	Without associated conditions: Low-Moderate With associated conditions: Moderate-High
  Uncontrolled hyperthyroidism	High

   

  Does my child’s medication place them at increased risk?

  Medication	Brand/Other Names	SARS-CoV2 Complication Risk
  Insulin	all brands	Low
  ACE-inhibitors (Lisinopril, Captopril, Enalapril)		Low
  Cabergoline	Dostinex	Low
  Desmopressin	DDAVP	Low
  Fludrocortisone		Low
  Growth Hormone	all brands	Low
  Hydrocortisone	Cortef	Low
  Liraglutide	Synthroid, Levothroid, others	Low
  Metformin		Low
  Methimazole	Tapazole	Low
  Prednisone (when used only to treat adrenal insufficiency)		Low
  Cholesterol lowering HMG-CoA Reductase Inhibitors	“Statins”	Low
  Fenofibrates	Lofibra, Tricor	Low
  Gemfibrozil	Lopid	Low
  Birth control pills	all brands containing estrogen	Low-Moderate

   

  Go to main Diabetes Program page.

  Go to main Endocrinology page.

• Down Syndrome

  Children with Down syndrome encompass a wide spectrum. Currently, we do not know if children with Down syndrome are more likely to get sick with COVID-19. In general, people with Down syndrome are more likely to get infections and many children with Down syndrome have other medical problems and take medications that could make them more at risk for severe illness from COVID-19. For these reasons, it is very important to follow the recommended precautions to prevent COVID-19 in children with Down syndrome.

  In the absence of a co-occurring high-risk medical condition or immune-suppressing medication, return to school in-person may benefit and support these children by establishing a consistent routine, opportunities for social interaction, encouraging a sense of normalcy, and reducing burden on caregivers. However, this decision should be made in consultation with your health professional.

  Please see the links below for more information pertaining to a child with Down syndrome and other developmental and behavioral challenges.

  Q&A on COVID-19 and Down Syndrome

  Go to Developmental Behavior Pediatrics COVID-19 Resources page

  Go to main Down Syndrome page

• Gastroenterology or Liver

  Because clinical symptoms of COVID-19 can include fever, and diarrhea, as well as a loss of sense of taste, our GI patients may be more affected than the general pediatric population. Moreover, liver injury has been described in patients with COVID-19, so our patients with chronic liver disease should also be aware of their risks. There are also children who have multiple medical conditions; therefore, parents should also review the recommendations for the other conditions involved. Moreover, talking with your primary care physician or specialist about your decision is also recommended.

  There is a separate section for children with Inflammatory Bowel Disease and Liver Disease that require medications that may lower the immune system function. In the current state of rising numbers of COVID-19 cases in Dallas County and the surrounding areas, moderate and high-risk groups should choose at home learning if the patient and parents’ situation safely and reasonably allow for that option. This information may change, so please continue to check back.

  Diagnosis	Status	Risk
  Abdominal Migraines		Low
  Achalasia		Low
  Alagille Syndrome	Mild liver disease	Low
  	Moderate liver disease	Low-Moderate
  	Severe liver disease	Moderate
  Anorectal Malformation		Low
  Autoimmune liver disease	On Prednisone/Prednisolone	Moderate
  	On Imuran or 6-MP	Moderate
  Biliary Atresia	Mild liver disease	Low
  	Moderate liver disease	Low-Moderate
  	Severe liver disease	Moderate
  Celiac Disease		Low
  Constipation		Low
  Cyclic Vomiting Syndrome		Low
  Eosinophilic Esophagitis and Gastroenteritis	EoE/EG on diet therapy or PPI	Low
  	EoE/EG on swallowed budesonide	Low
  	EoE/EG on Entocort	Low
  	EoE/EG on biologic therapy	Low
  Failure to Thrive and Malnourished	Mild	Low
  	Moderate	Low
  	Severe	Moderate
  Fatty Liver Disease		Low
  Feeding problems with G-Tube	Not malnourished or mild	Low
  	Severely malnourished	Moderate
  Functional Abdominal Pain		Low
  Gastroesophageal Reflux (GERD)		Low
  Gastroparesis		Low
  Gluten Intolerance/Sensitive		Low
  Hepatitis B		Low-Moderate
  Hepatitis C		Low-Moderate
  Hirschsprung’s Disease	Without Ileostomy or colostomy	Low
  	With Ileostomy or colostomy	Low-Moderate
  Intestinal Pseudo-obstruction	Without ileostomy	Low
  	With ileostomy	Low
  	With TPN*	Moderate
  Inflammatory Bowel Disease		See our IBD section
  Irritable Bowel Syndrome		Low
  Short Gut Syndrome	Without Ileostomy or TPN	Low
  	With Ileostomy	Low
  	With TPN*	Moderate
  Wilson’s Disease		Low-Moderate

   

  *TPN in itself does not pose a risk for COVID-19 infection; however, if a patient with a central line has a fever, they must go to the ER to be evaluated for cause of fever, which includes a COVID-19 test and a blood culture.

  There are special consideration to patients with chronic liver disease. For instance, Fatty Liver patients who are obese may have a more severe illness with COVID-19 infection. In addition, those patients with chronic liver disease may also pose liver-related complications with COVID-19 because liver injury has occurred in infected patients. With that said, liver enzyme elevation is usually mild in COVID-19 disease and typically recovers without treatment.

  Patients who are not immunocompromised but are at risk of dehydration when they develop diarrhea, may also be more affected but COVID-19 infection.

  Go to main Gastroenterology page.

• Genetics / Metabolics

  Does my child’s diagnosis place them at increased risk?

  Children with certain inborn errors of metabolism may have significant associated risks if they were to have COVID-19 or its complications. Other disorders are predicted to have a risk and essentially the same as other children their age.

  The risk of complications could arise either from an acute metabolic decompensation with symptoms of the specific inborn error of metabolism, or from physiologic changes associated with the inborn error of metabolism which could predispose to worse manifestations of COVID-19.

  Below is a list of some of the inborn errors of metabolism we see most often in our metabolic clinic; this is not a comprehensive list of all disorders and each case can have variables which would merit specific rating based on the clinical manifestations of the child.

  Diagnosis	Risk
  Carnitine uptake defect	Low
  Citrullinemia	High
  Cobalamin C defect	Low
  Galactosemia	Low
  Homocystinuria	Low to Moderate
  Long chain fatty acid oxidation disorders (CPT1, CPT2, LCHAD, CACT)	Moderate
  MCAD	Low
  Methylmalonic aciduria	High
  Mucopolysaccharidosis	Moderate
  Ornithine Transcarbamylase (OTC)	High
  Phenylketonuria (PKU)	Low
  Propionic aciduria	High
  VLCAD   with cardiomyopathy	High
  VLCAD   without cardiomyopathy	Low

   

  Does my child’s medication place them at increase risk? 

  To our knowledge none of the medications or supplements we use in the management for inborn errors of metabolism is associated with an increased risk of acquiring COVID-19 or increase the risk of complications associated with the condition. Continued use of these medications is encouraged as they can aid in providing metabolic stability and decreasing associated risks.

  Go to main Genetics Program page.

• Heart / Cardiology

  Does my child’s diagnosis place them at increased risk?

  COVID-19 can affect children of all ages; however, based on current data, children are less likely than adults to get severely ill. While reports from the Centers for Disease Control (CDC) suggests that adults with heart disease are at higher risk of severe illness from COVID-19, limited data is available to support increased risk in children with heart disease.  While we recognize that there is data limitation, the unknown risk may impose a real threat.

  Children with cardiac disease, especially those with congenital heart disease, may have concomitant pulmonary disease and other comorbidities that may presumably increase the risk for complications related to COVID-19 infection.

  These recommendations are subject to change as new data becomes available.

  Diagnosis	Risk
  Unrepaired complex congenital heart disease	High
  Fontan patients with protein losing enteropathy	High
  Fontan patients with plastic bronchitis	High
  Any cardiac disease with associated moderate or severe heart dysfunction but patient has congestive symptoms or symptoms difficult to control.	High
  Pulmonary hypertension/Eisenmenger	High
  Fontan patients with normal heart function	Moderate
  Any cardiac disease with associated moderate or severe heart dysfunction but patient has no congestive symptoms or has mild symptoms easily to be managed	Moderate
  Repaired congenital heart disease with hemodynamic significant residual lesion	Moderate
  Repaired congenital heart disease with no residual lesion and normal heart function	Low
  Repaired congenital heart disease without hemodynamic significant residual lesion	Low
  Mild heart disease not requiring intervention	Low
  Systemic hypertension	Low

   

  For further questions regarding your child’s medical diagnosis/condition, please contact your primary cardiologist.

  We strongly recommend our patients and all family members strictly adhere to standard precautions (masks in public, social distancing, hand washing, avoiding crowds, avoid touching your face in public, etc.).

  Go to main Heart / Cardiology Program page.

• Hematology

  The COVID-19 pandemic continues to expand across North Texas. The situation remains fluid, with many children, adolescents and young adults having been infected with COVID-19 in the past few weeks. Fortunately, most healthy children and young adults who are infected with COVID-19 appear to have relatively mild infections. Although limited data exists, it appears that immunocompromised children often have a comparatively less severe medical course than previously reported elderly people and those with pre-existing conditions, including cancer, who are infected with COVID-19. Even so, families of children with blood disorders and their physicians share concerns about children returning to in-classroom school in the fall.

  The recently published American Academy of Pediatrics (APP) guidelines encourage schools to provide in-classroom learning for healthy children. Among the reasons supporting in-classroom learning include improved academic instruction, maintaining social and emotional skills, safety, reliable nutrition, physical/speech and mental health therapy, and opportunities for physical activity. In response, many schools across North Texas will be open this fall for both in-classroom and remote learning.

  Children with hematological diseases are a medically vulnerable population. The AAP guidelines do not address the unique circumstances of whether children with hematological diseases, including those being treated with immunosuppressive therapy, sickle cell disease, and other hematological diseases should be encouraged to participate in in-classroom learning. The purpose of the guidelines below are to provide patients, their families and their healthcare providers a risk assessment of returning to school for patients with hematological diseases.

  Does my child’s diagnosis place them at increased risk?

  Diagnosis	Risk
  Iron Deficiency or Iron Deficiency Anemia	Low
  Hereditary Spherocytosis	Low
  Bleeding Conditions: Von Willebrand’s Disease Hemophilia / Clotting Factor Deficiencies	Low
  Clotting Conditions: Thrombophilia Deep venous thrombosis and pulmonary embolism	Low
  Bone Marrow Failure on Observation or Off-Therapy: Inherited Bone Marrow Failure (Fanconi Anemia, Shwachman Diamond Syndrome, Dyskeratosis Congenita, Diamond Blackfan Anemia, Severe Congenital Neutropenia) Acquired Bone Marrow Failure (Aplastic Anemia)	Moderate   Low-Moderate
  Bone Marrow Failure on Active Therapy (see medication list) Inherited Bone Marrow Failure (Fanconi Anemia, Shwachman Diamond Syndrome, Dyskeratosis Congenita, Diamond Blackfan Anemia, Severe Congenital Neutropenia) Acquired Bone Marrow Failure (Aplastic Anemia)	Moderate-High High
  Immune Mediated Cytopenias on Observation: Immune Thrombocytopenia (ITP) Autoimmune Hemolytic Anemia Autoimmune Neutropenia Evans Syndrome	Low
  Immune Mediated Cytopenias on Active Therapy (see medication list): Immune Thrombocytopenia (ITP) Autoimmune Hemolytic Anemia Autoimmune Neutropenia Evans Syndrome	Low-Moderate
  Autoimmune Lymphoproliferative Disorders (see medication list)	Low-Moderate
  Thalassemia Major/Intermedia: On Chronic Transfusions and Chelation Therapy On Observation/Episodic Transfusion	Moderate Low
  Sickle cell anemia/sickle cell disease	High

   

  Does my child’s medication place them at increase risk?

  Common Medications	ARS-CoV2 Complication Risk
  Ferrous Sulfate or IV Iron	Low
  Tranexamic Acid	Low
  DDAVP	Low
  Factor replacement	Low
  G-CSF	Low
  IVIG	Low
  Eltrombopag	Low
  Romiplostim	Low
  Hydroxyurea	Low
  Penicillin/PenVK	Low
  Ibuprofen	Low
  Tylenol	Low
  Tylenol with Hydrocodone	Low
  Mycophenolate	Moderate
  Cyclosporine	Moderate
  Tacrolimus	Moderate
  Sirolimus	Moderate
  Prednisone	Moderate
  Iron chelation therapy	Moderate
  Rituximab	High

       

  Go to main Hematology Program page.

• Hematopoietic Stem Cell Transplant

  The AAP guidelines do not address the unique circumstances of whether children being treated with a hematopoietic stem cell transplant (HSCT) should be encouraged to participate in in-classroom learning. 

  Without question, children who have undergone HSCT are a medically vulnerable population. The multiple chemotherapy and immunosuppressive agents utilized during the transplant course and for complications post-transplant result in the child being at a high risk for opportunistic infections. 

  As a result, we believe that children who have recently undergone HSCT or are being treated for certain complications of HSCT should be actively encouraged to participate in remote learning instruction. 

  Where possible, they should avoid environments where they may have an increased at risk of COVID19 infections, including the school environment, mass transit, and crowded public spaces where socially distancing is difficult. Furthermore, they should be encouraged that good hygiene, including hand washing and wearing a mask, is an important strategy to reduce the risk of infection with COVID19.

  It is our recommendation that the following post-transplant patients engage in online learning at this time:

  Low Risk We also recognize that are children who have undergone transplant and are doing well and off of immunosuppression. These children may benefit from the in-classroom academic environment and should be allowed to attend in-classroom school.

  Moderate Risk Any allogeneic stem cell transplant patient who remains on immunosuppressive therapy (prophylactic OR treatment dosing): Including patients more than 100 days post-transplant who have not been weaned off of their prophylactic immunosuppressive regimen. Including patients treated for both acute and chronic graft versus host disease (GVHD) with immunosuppressive drugs.

  High Risk All allogeneic stem cell transplant patients within 100 days from receiving their transplant. All autologous stem cell transplant patients within 60 days from receiving their cells; after 60 days, the decision to return to in-person learning will be made in conjunction with their treating oncologist based on need for future treatment.

   

  Go to main Stem Cell Program page.

• Inflammatory Bowel Disease

  Does child’s diagnosis or other complications place them at increased risk?

  First, we recognize children with Inflammatory bowel disease (IBD; Crohn’s disease and ulcerative colitis) represent a wide spectrum of diseases that affect varying lengths of intestines and colon. Furthermore, there have been no convincing studies at this time that demonstrate pediatric patients with IBD are at significantly increased risk for SARS-CoV2.

  We recommend our patients and families take standard precautions (masks in public, social distancing, hand washing, avoiding crowds, etc.). We also have not seen any data to suggest that infection with SARS-CoV2 can result in relapse of any of these conditions

  Does my child’s medication place them at increased risk?

  We have been tracking available data to determine if the medications used in management of IBD increase the risk of contracting SARS-CoVI2 virus and also whether these medications increase complications from the SARS-CoV2 virus, if a person becomes infected.

  It is important to know that data about this topic is very limited, but the following table outlines the most common medications used in IBD and the relative risk, though clearly does not represent all medications that are utilized in our clinic.

  We rate the medications as low, moderate or high risk based on available data and our concerns based on how these medications effect the immune system. As mentioned above, these recommendations and categories are subject to change based on new data becoming available.

  We recommend continuing your child’s medications including infusions and injections. Having active bowel inflammation is a bigger risk for infection than being on your medications that are controlling the overactive immune system of IBD. Being off medications places you at risk for a relapse, which could mean steroids, which would be worse than appropriately dosed effective IBD medications.

  Medication	Brand Names	SARS-CoV2 Complication Risk
  Methylprednisolone (IV dosing)	Solumedrol	High
  Prednisone	Orapred, Deltasone (and others)	Moderate
  Tacrolimus	Prograf	Moderate
  Sirolimus	Rapamune	Moderate
  Azathioprine/6-mercaptopurine (6MP)	Imuran	Moderate
  Tofacitinib	Xeljanz	Moderate
  Budesonide	Entecort/Uceris	Low
  Methotrexate	Rasuvo, Otrexup (and others)	Low
  Infliximab	Remicade	Low
  Adalimumab	Humira	Low
  Certolizumab	Cimzia	Low
  Vedolizumab	Entyvio	Low
  Ustekinumab	Stelara	Low
  Sulfasalazine	Azulfidine	Low
  Mesalamine/5ASA medications	Lialda/Apriso/Colazol/Delzicol	Low
  Diet Therapies	Exclusive enteral nutrition (EEN), Specific Carbohydrate Diet (SCD), Crohns Disease exclusion diet (CDED)	Low

   

  For more information visit the Crohns Colitis Foundation page about COVID-19.

  Go to main Inflammatory Bowel Disease Program page.

• Immunology

  Does child’s diagnosis or other complications place them at increased risk?

  Diagnosis Group	Example Diagnoses	Risk
  Severe defects in adaptive immunity	Severe Combined Immunodeficiency Disorder (SCID) Complete athymia (e.g. DiGeorge, FoxN1)	High
  Combined immune deficiencies, affecting number or function of T and B cells	Hyper-IgE Wiskott – Aldrich CD40L deficiency Ataxia-telangiectasia DOCK8 deficiency	High
  Agammaglobulinemia and severe antibody deficiencies	Hyper- IgM's Common Variable Immunodeficiency (CVID) X-Linked Agammaglobulinemia	High
  Neutrophil Defects	Chronic Granulomatous Disease Cyclical Neutropenia	Low

   

  Does my child’s medication place them at increased risk?

  Regarding immunoglobulin therapies, these should be continued. The Plasma Protein Therapeutics Association (PPTA) has issued a statement (February 17, 2020) stating that the virus, a lipid envelope virus, is not a concern for the safety of plasma protein therapies, including immunoglobulin (Ig), manufactured by PPTA member companies (this covers all U.S. suppliers).  According to PPTA, “based on strict screening procedures for plasma donors and the established processes of virus inactivation and removal during the manufacturing of plasma-derived products, PPTA concludes that the SARS-CoV-2 is not a concern for the safety margins of plasma protein therapies manufactured by PPTA member companies.”

  Relative to the medications we frequently prescribe, we have been tracking available data to determine if the medications increase the risk of complications from the SARS-CoV2 virus, if a person becomes infected. It is important to know that data about this topic is very limited, but the following table outlines the most common immunomodulator prescriptions and the relative risk. We rate the medications as low, moderate or high risk based on available data and our concerns based on how these medications effect the immune system. As mentioned above, these recommendations and categories are subject to change based on new data becoming available.

  Medication	SARS-CoV2 Complication Risk
  Interferon Beta	Low
  IVIG	Low
  Dexamethasone	Moderate
  Mycophenolate	Moderate
  Sirolimus	Moderate
  Tacrolimus Tacrolimus	Moderate
  Prednisone	Moderate
  Rituximab	High

   

  If your child’s diagnosis is not listed in the categories above, we can discuss which category their specific diagnosis may fall into, and make recommendations as appropriate.

  We are tracking this situation closely and communicating with other physicians in the Clinical Immunology Community. As more information on disease prevention in immunocompromised patients becomes available we will modify plans accordingly.

  Go to main Immunology Program page.

• Nephrology

  Does child’s diagnosis or other complications place them at increased risk?

  Nephrology patients have a wide variety of diagnoses and often have other factors that can affect their risk level, such as status of their illness and prescribed medications. If your child is on immunosuppression, please review the medication table below. If your child has other medical issues, such as lung, heart, liver, etc, you should review the recommendations for those other subspecialties as well, which can be found on this same website. 

  The table below summarizes some of the more common nephrology diagnoses. If you do not see your child’s diagnosis or have any other questions, please contact your child’s physician. Kidney transplant patients should review the recommendations for transplant which are in a separate section. In addition, this table simply summarizes risk level based on diagnosis, please see additional information below regarding medication risk as well as other factors that may contribute to your decision about sending your child back to in-person school.

  Diagnosis	Risk
  Nephrotic Syndrome in remission on no immunosuppression Includes children without biopsy, minimal change disease, FSGS, membranous disease, and C3 glomerulopathy	Low
  Nephrotic syndrome in remission on immunosuppression Includes children without biopsy, minimal change disease, FSGS, membranous disease, and C3 glomerulopathy	Depending on medications: Moderate-High
  Nephrotic syndrome in relapse Includes children without biopsy, minimal change disease, FSGS, membranous disease, and C3 glomerulopathy	High
  End Stage Renal Disease on dialysis without immunosuppressive medications	Low-Moderate
  End Stage Renal Disease on dialysis also on immunosuppressive medications	High
  Lupus Nephritis – influenced by immunosuppressive therapy.  (see medication list)	Moderate-High
  Other autoimmune nephritis – influenced by immunosuppressive therapy Includes ANCA, Goodpasture’s, Granulomatosis with polyangiitis (Wegener's)	Moderate-High
  Chronic kidney disease not on dialysis and not taking immunosuppressive medications	Low
  Kidney cysts	Low
  Kidney stones	Low
  High urine calcium levels	Low
  Bartter or Gitelman syndrome	Low
  Pseudohypoaldosteronism	Low
  Renal tubular acidosis	Low
  Solitary kidney or horseshoe kidney	Low
  Microscopic hematuria	Low
  Frequent urinary tract infections (UTI)	Low
  Obstructive uropathy with need to catheterize bladder	Low
  Hypertension with obesity	Moderate
  Hypertension without obesity	Moderate
  Atypical HUS	High

   

  We recommend our patients and all family members strictly adhere to standard precautions (masks in public, social distancing, hand washing, avoiding crowds, etc.)

  Does my child’s medication place them at increased risk?

  Relative to the medications we frequently prescribe, we have been tracking available data to determine if the medications increase the risk of complications from the SARS-CoV2 virus, if a person becomes infected. It is important to know that data about this topic is very limited, but the following table outlines the most common immunomodulator prescriptions and the relative risk.

  We rate the medications as low, moderate or high risk based on available data and our concerns based on how these medications effect the immune system. As mentioned above, these recommendations and categories are subject to change based on new data becoming available.

  Medication	SARS-CoV2 Complication Risk
  ACE inhibitors - Enalapril, Lisinopril	Low
  Angiotensin receptor blockers – Losartan, Telmisartan	Low
  Diuretics – Chlorothiazide (Diuril), Hydrochlorothiazide, Lasix, Metolazone	Low
  High blood pressure medications such as Amlodipine, Clonidine, Atenolol, Metoprolol, Carvedilol	Low (although increased risk of dehydration with diarrhea or vomiting)
  Statins for high cholesterol	Low
  Prednisone	Moderate
  Mycophenolate (Cellcept)	Moderate
  Tacrolimus (Prograf)	Moderate
  Sirolimus (Rapamune)	Moderate
  Plasmapheresis	Moderate
  IV Cyclophosphamide (Cytoxan)	High
  Methylprednisolone (Solumedrol) high dose pulse	High
  Rituximab	High
  IVIG	High

    

  Go to main Nephrology page.

• Neuromuscular

  Diagnosis	Risk
  Chronic Inflammatory Demyelinating Polyneuropathy	Moderate
  Congenital Myopathies with respiratory Needs	High
  Duchenne Muscular Dystrophy	High
  Myasthenia Gravis	High
  Spinal Muscular Atrophy Type 1	High
  Spinal Muscular Atrophy Type 2	High

   

  Go to main Neuromuscular Program page.

• Oncology

  Although limited data exists, it appears that immunocompromised children often have a comparatively less severe medical course than previously reported elderly people and those with pre-existing conditions, including cancer, who are infected with COVID19. Even so, families of children with cancer, certain blood disorders, or have received a bone marrow transplant and their physicians share concerns about immunocompromised children returning to in-classroom school in the fall.

  The recently published American Academy of Pediatrics (APP) guidelines encourage schools to provide in-classroom learning for healthy children. Among the reasons supporting in-classroom learning include improved academic instruction, maintaining social and emotional skills, safety, reliable nutrition, physical/speech and mental health therapy, and opportunities for physical activity. In response, many schools across North Texas will be open this fall for both in-classroom and remote learning.

  The AAP guidelines do not address the unique circumstances of whether children being treated with immunosuppressive chemotherapy for cancer should be encouraged to participate in in-classroom learning. Without question, children with cancer who are being treated with immunosuppressive chemotherapy are a medically vulnerable population. The multiple immunosuppressive chemotherapy agents utilized over extended time intervals collectively result in the child being at a high risk for opportunistic infections.

  Potential consequences of being infected with COVID-19 include morbidity and mortality due to the infection itself and potential interruptions in chemotherapy administration due to an infection. As a result, we believe that children with cancer who are receiving immunosuppressive chemotherapy should be actively encouraged to participate in remote learning instruction. Where possible, they should avoid environments where they may have an increased at risk of COVID19 infections, including the school environment, mass transit, and crowded public spaces where socially distancing is difficult. Furthermore, they should be encouraged that good hygiene, including hand washing and wearing a mask, is an important strategy to reduce the risk of infection with COVID19.

  We also recognize that here are certain populations of children whose cancer treatments result in minimal immunosuppression. These children may benefit from the in-classroom academic environment and should be allowed to attend in-classroom school.

  Low-risk diagnoses: Treatment includes surgery only Treatment includes radiation therapy only Low-Risk Wilms Tumor, Desmoid Tumors, Langerhans’ Cell Histiocytosis Cancer survivors without cancer treatment-related late effects (such as heart and pulmonary dysfunction, high blood pressure, kidney damage) Patients being treated with targeted therapies that are not associated with significant immunosuppression

  High-risk diagnoses: Leukemia, Lymphoma, and Hodgkins Disease High-Grade Sarcoma Intermediate- and High-Risk Neuroblastoma High-Risk Wilms Tumor High-Grade (WHO grade III and IV) Brain Tumors

   

  Go to main Oncology Program page.

• Pulmonology

  The risk of developing symptoms of the syndrome known as COVID-19 as a result of the novel coronavirus (SARS CoV-2) is increased when there is an increased number of persons indoors like in a school. While the overall risk for COVID-19 is overall lower for children than for adults, there are some pulmonary conditions for which returning for school poses an increased risk.

  To help guide parents decide on whether they should send their child with a respiratory condition back to school, in the table below we have categorized various pulmonary conditions as low, moderate and high risk, based on expert consensus opinion. Currently, we are experiencing a high level of new cases of COVID-19 in Dallas county and surrounding areas. Therefore, we, as pediatric pulmonologists, recommend that moderate and high-risk groups consider virtual learning if possible.

  Please note that the risks categorized below is a general guide and is not based on any collected medical data regarding actual risk for these medical conditions. Our guidance is subject to change based on daily case counts. Above all else, one general rule of thumb is that if your child has chronic lung condition and has poorly controlled respiratory symptoms, that the overall risk in sending that child back to school is high.

  Diagnosis	Severity	Risk
  Asthma*	Severe persistent	High
  	Uncontrolled moderate persistent**
  	Well controlled Moderate persistent	Moderate
  	Mild asthma	Low
  Cystic fibrosis⁺	FEV1 < 90%, hospitalization(s) in the past 12 months, history of liver disease/ recurrent pancreatitis, body mass index < 50%	High
  	FEV1 ≥ 90%, on gene modulator therapy, body mass index > 50%, no admissions in the previous 12 months, +/- “mild” mutations	Moderate
  Primary Ciliary Dyskinesia	FEV1 < 90%, or hospitalization(s) in the past 12 month	High
  	FEV1 ≥ 90% and no hospitalization(s) in the past 12 months	Moderate
  Bronchopulmonary dysplasia (BPD)	With asthma, > 1 ER visit or hospitalization in previous 12 months OR on oxygen	High
  	With asthma, well controlled**	Moderate
  	No asthma, no hospitalizations for previous 12 months	Low
  Interstitial lung disease	Poorly controlled, on oxygen	High
  	Well controlled, normal pulmonary function testing	Low
  Pulmonary manifestations of neuromuscular disease (e.g. spinal muscular atrophy, muscular dystrophy)		High
  Bronchiolitis obliterans		High
  Tracheostomy dependence/ ventilatory dependence		High
  Pharyngeal dysphagia leading to chronic pulmonary aspiration	Completing/ completed speech therapy	Low
  	Newly diagnosed/ poorly controlled	Moderate-High⁺⁺
  Cerebral palsy/Developmental delay with co-existing chronic lung disease	Requires oxygen or ventilator with sleep	High
  	No hospitalizations in previous 12 months	Low
  	>1 hospitalization in previous 12 months	Moderate
  Chronic coughing entirely due to gastroesophageal reflux		Low
  Other chronic lung diseases (examples include: post-infectious bronchiolitis obliterans, bronchiectasis (not cystic fibrosis), pulmonary hemosiderosis, pulmonary manifestations of oncologic or rheumatologic disease)	>1 hospitalization in previous 12 months	High
  	No hospitalizations in previous 12 months	Moderate

   

  *Children with asthma AND obesity may have a higher overall risk 

  ** Poorly controlled asthma is defined as requiring rescue inhaler (ProAir/ Ventolin/ Albuterol/ Xopenex/ Ipratropium or Atrovent) > 2 times per week, cough/wheezing more than twice per week, night-time cough more than 2 times per month, difficulty breathing with daily activities, or > 2 asthma attacks requiring oral steroids in the previous 12 months. If parents note these symptoms, we recommend scheduling a visit with primary care provider or asthma specialists to adjust medications.

  +Patients with cystic fibrosis in general are at high risk of losing lung function unexpectedly. As experts, we feel that some children with cystic fibrosis may have a lower risk. We recommend that you discuss the specific risk of your child with your specialist.

  ++High risk if child with > 1 hospitalization for respiratory problem in the previous 1-2 years.

  Does my child’s diagnosis or other complications place them at increased risk?

  • Inhalers: Inhaled medications used by children with asthma are very low risk. In fact, children should continue their inhaled medications to lower the risk of having complications of COVID-19, because these medicine help control lung disease.
  • Metered dose inhalers (MDIs) vs Nebulized medications:  Neither type of medication increase a child’s risk for COVID-19, however, we encourage the use of MDIs (inhalers) rather than use of nebulized medications. Nebulized medications lead to more aerosolized particles from the lungs of child using the nebulizer machine. If that child is infected with COVID-19, then he/she could pass along the virus to nearby persons through the air. There is less chance of passing the infection to someone else if a child uses an inhaler. If use of an inhaler is not possible, and your child requires a breathing treatment, then medication via nebulizer should be used to treat your child.
  • Have a rescue inhaler at school:  We encourage children with asthma to have an extra rescue inhaler (such as albuterol, ipratropium, levalbuterol) and spacer with them at school. Your child’s  primary care provider or specialist will be more than happy to provide schools with letters so that children can keep their inhalers and spacers with them at school.

   

  If my child is lower risk, how do I best prepare for my child's return to school?

  • Have an updated Asthma Action Plan for your child with asthma:  We recommend that parents make sure that their child with asthma has an updated asthma action plan at home and in school that is easily accessible for reference, and to make sure that their inhalers are not expired.  It is also important to never run out of Albuterol – if you notice that the number of available doses left on the inhaler is getting close to zero, it’s time to request a refill.
  • Follow your treatment plan:  Lung disease that is currently well controlled, even if with the assistance of inhaled medications, places your child in the best possible position to recover from COVID-19 if he/she should contract the disease. This includes daily controller medication for children with asthma, daily airway clearance medication for children with cystic fibrosis, primary ciliary dyskinesia, bronchiectasis and cerebral palsy. 
  • Seasonal influenza (Flu) vaccine: We also advise parents that it’s imperative to ensure their child receives an influenza vaccine (flu shot) in the fall when these become available. We regularly see increased levels of respiratory disease during influenza season, and it is possible that the novel coronavirus together with influenza could make this upcoming influenza season particularly difficult for children with chronic respiratory conditions.
  • Healthcare providers are there to help: Always seek the advice of your healthcare provider with any questions you may have regarding your child’s medical condition.  Never disregard professional medical advice or delay in seeking it because of something you have read in a public group(s) or website. If you think you may have a medical emergency, call your healthcare provider or 911 immediately.

   

  Go to main Pulmonology page.

• Rheumatology

  Does my child’s diagnosis or other complications place them at increased risk?

  First, we recognize children with rheumatic disease represent a huge spectrum of disease, and can have any number of other medical conditions and complications. Furthermore, there have been no convincing studies at this time that demonstrate pediatric patients with rheumatic conditions are at significantly increased risk for SARS-CoV2. However, patients with systemic connective tissue disease (e.g., systemic lupus erythematosus, mixed connective tissue disease, juvenile dermatomyositis, systemic sclerosis, systemic vasculitis) often have other specific organs involved that may place them at higher risk. Particularly if your child has significant lung, cardiac or renal involvement, we urge you to contact your child’s pulmonologist, cardiologist or nephrologist for additional recommendations.

  Apart these issues, we recommend our patients and families take standard precautions (masks in public, social distancing, hand washing, avoiding crowds, etc.). We also have not seen any data to suggest that infection with SARS-CoV2 can result in relapse of any of these conditions.

  Does my child’s medication place them at increased risk?

  Medication	Brand Names	SARS-CoV2 Complication Risk
  Cyclophosphamide	Cytoxan	High
  Rituximab	Rituxan	High
  Methylprednisolone (“pulse”/IV dosing)	Solumedrol	High
  Prednisone	Orapred, Deltasone (and others)	Moderate
  Mycophenolate	Cellcept, Myfortic	Moderate
  Cyclosporine	Neoral (and others)	Moderate
  Tacrolimus	Prograf	Moderate
  Azathioprine	Imuran	Moderate
  Belimumab	Benlysta	Moderate
  Ixekizumab	Taltz	Moderate
  Tofacitinib	Xeljanz	Moderate
  Hydroxychloroquine	Plaquenil	Low
  Methotrexate	Rasuvo, Otrexup (and others)	Low
  Etanercept	Enbrel	Low
  Adalimumab	Humira	Low
  Abatacept	Orencia	Low
  Secukinumab	Cosentyx	Low
  Apremilast	Otezla	Low
  Sulfasalazine	Azulfidine	Low
  Leflunomide	Arava	Low
  Ustekinumab	Stelara	Low
  Infliximab	Remicade	Low
  Tocilizumab	Actemra	Low
  Anakinra	Kineret	Low
  Canakinumab	Ilaris	Low
  Colchicine	Colcrys	Low
  All NSAID medications	Examples: Naprosyn, Meloxicam, Celebrex, Ibuprofen, Aspirin	Low
  Intra-articular corticosteroid injections	Also known as “joint injections"	Low
  IVIG/subcutaneous immunoglobulin	Gamunex, Privigen, Hizentra (and others)	Low

   

  Relative to the medications we frequently prescribe, we have been tracking available data to determine if the medications increase the risk of complications from the SARS-CoV2 virus, if a person becomes infected. It is important to know that data about this topic is very limited, but the following table outlines the most common immunomodulator prescriptions and the relative risk, though clearly does not represent all medications that are utilized in our clinic.

  We rate the medications as low, moderate or high risk based on available data and our concerns based on how these medications effect the immune system. As mentioned above, these recommendations and categories are subject to change based on new data becoming available.

  Go to main Rheumatology page.

• Sleep Disorders

  Sleep is a very important physiologic process for children. Disrupted or fragmented sleep can decrease the ability of the body to fight infections and illnesses. Children need a higher amount of sleep time in comparison to adults. A reduced sleep time in a child can have detrimental effects on his/her overall health including difficulty to pay attention in school and/or having a learning difficulty.

  For your reference, in the table below, we have categorized various sleep conditions as low, moderate and high risk, based on expert consensus opinion. We recommend that in the current state of increased number of cases of COVID-19 throughout Dallas county and surrounding areas, moderate and high-risk groups choose virtual learning if possible, for parents to arrange.

  Diagnosis	Severity	Risk
  Obstructive sleep apnea and central sleep apnea	Needing positive airway pressure (PAP) Therapy – Inadequate adherence	Moderate
  	Needing positive airway pressure (PAP) therapy – adequate adherence Mild-Moderate on medications or oxygen   Note: Medicare/Medicaid defines positive airway pressure therapy (PAP) adherence as using the device >4 hours per night on at least 70% of nights.	Low
  Narcolepsy		Low
  Insomnia/sleep deprivation Note: The American Academy of Pediatrics recommended sleep times for children.		If getting inadequate sleep for the age: Moderate If getting adequate sleep for the age: Low
  Restless legs syndrome		Low

   

  Does my child’s medication place them at increased risk?

  • Anti-inflammatories: We do not believe that anti-inflammatories as nasal steroids or leukotriene inhibitors commonly used for sleep apnea would place them at increased risk of contracting the virus leading to the disease known as COVID-19.
  • Wakefulness-promoting agents or stimulants: We do not believe that medications used in children with Narcolepsy would place them at increased risk for COVID-19. We recommend Narcolepsy patients to continue taking their medications as instructed by their sleep provider in addition to other interventions as regular sleep schedule and scheduled naps.
  • Positive airway pressure (PAP) therapy: We recommend to continue using PAP therapy at home on a patient who is not COVID-19 positive. If a patient is sick with COVID-19, risks and benefits of using PAP therapy at home should be discussed with your sleep provider as there might be an increased risk of transmission of COVID-19 to others at home if PAP is continued.

   

  Go to main Sleep Disorders page.

• Solid Organ Transplant

  Does my child’s diagnosis or other complications place them at increased risk?

  First, we recognize children with a transplant are not all the same and that they represent a wide clinical spectrum and these children can have any number of other medical conditions and complications.

  Although there are no studies at this time to demonstrate pediatric patients with a transplant are at a significantly increased risk for SARS-CoV2, transplanted patients are immunocompromised, and thus infections pose different risks for these children than patients without transplants. However, having a transplant alone does not put your child in the high-risk category. As you know, transplant patients might have other co-morbidities that can affect their overall risk of infection.

  Solid Organ Transplant has created a table to help identify low to high- risk transplant patients.

  Transplant Status	Risk
  Time from Transplant less than 1 year	High
  Time from Transplant greater than 1 year, low level monotherapy immunosuppression, and no augmented immunosuppression for the treatment of rejection within the last year	Low
  Time from Transplant greater than 1 year, 2 prescribed immunosuppressant medications, and no augmented immunosuppression for the treatment of rejection within the last year	Moderate
  Time from Transplant greater than 1 year and 3 or more prescribed immunosuppressant medications and no augmented immunosuppression for the treatment of rejection within the last year	Moderate
  Time from Transplant greater than 1 year and augmented immunosuppression either due to rejection or chemotherapy(dependent on drug)	Moderate-High

   

  Your child’s immunosuppression regimen is very patient specific, so please contact your transplant team to discuss which category best describes your child and which school option is best.

  We recommend our patients and all family members strictly adhere to standard precautions (masks in public, social distancing, hand washing, avoiding crowds, etc.)

  In addition, any transplant patient with BMI> may be at increased risk for complication of COVID-19.

  Does my child’s medication place them at increased risk?

  We have been tracking available data to determine if the medications used after solid organ transplant increase the risk of complications from the SARS-CoV2 virus, if a person becomes infected. It is important to know that data about this topic is very limited

  We rate medications as low, moderate or high risk based on available data and our concerns based on how these medications effect the immune system. Time from transplant, the number of medications as well as the dose your child is currently taking, and the presence of other co-morbidities must be looked at before determining a risk category. As mentioned above, these recommendations and categories are subject to change based on new data becoming available, so please contact the transplant department if you have questions.

  Go to main Solid Organ Transplant page.

Additional questions to consider:

• What about household members with elevated risk?

  While this resource is specifically designed to guide return to school and thus focuses on the health conditions and treatments that may increase risk for children, it is important to acknowledge that an entire family unit shares the risk of return to school. If a sibling, parent, grandparent, or other household member has a health condition or treatment that increases their risk of complications from COVID-19, the same risk categories described for children likely apply.

  Another way of saying this is a household’s risk is defined by the person in the household with the highest risk. If there are four people in a house and one has moderate to high risk of complications from COVID-19, then all household members should follow the same precautions.

  While we do not yet fully understand the risk of transmissibility from children to adults, any high-risk medical condition or immune-compromising medication should be considered in the risk assessment. These guidelines can be used a resource for having conversations with the medical team caring for adults with increased risk who are household members with children that may be returning to school.

• What about other factors that influence decision-making?

  The information presented here is meant to help inform personal decisions about returning to school. We recognize that certain situations may make it difficult to follow these recommendations, and there is not a one-size-fits-all solution.

  Many families have two parents working outside the home, and in-person school is a necessity to maintain employment. Other families rely on the key resources provided in schools for access to important therapies, nutritious food, and learning accommodations. In addition to these, there are other circumstances which will influence personal decision making, and we support the individual discussions with your family, healthcare team, and school to guide decisions.

  For children at higher risk of returning to in-person school, we urge families to do the best they can to reduce risk of exposure (wear a mask, avoid excessive close contact, wash hands regularly, etc.), and we encourage healthy children to support their classmates in these efforts. Please remember to speak to your team of health professionals about specific nuances of your child’s care as you navigate these challenging decisions.

• What about children with special education plans and accommodations?

  Schools are working very hard to manage this unique situation for all students and are adapting educational programming. Likewise, procedures for accessing support services for students with disabilities may be altered in many situations. For example, meetings between the school, parents, and students to develop and review formal support services may be held by phone or videoconference.

  Parents and patients should be aware that students with disabilities maintain their rights in the remote learning environment and should work with their school personnel to establish and/or maintain formal support services (e.g., 504 Plans, Special Education IEP). Families may work with their Children’s team to gather documentation to share with the school to support such educational programming.

• Can my child return to play sports?

  Summer is typically a season for sports clearances and preparation for the upcoming sports seasons. In the era of COVID-19, there have been many questions and concerns surrounding the risks of returning to exercise and sports participation following COVID infection. Given the increased rate and severity of infection in the adult community, the recommendations for cardiac evaluation prior to exercise and sports participation are understandably extensive. The approach in the pediatric population, however, should reflect the severity of infection and the risk of long term cardiopulmonary compromise.

  As there is a significantly lower prospect of symptoms and sequelae in the pediatric population, the evaluation prior to sports participation should reflect this decreased risk appropriately. Accordingly, the pediatric algorithm for returning to sports differs from that in the adult community. Included below is the algorithm for evaluation and monitoring of pediatric patients following COVID-19 infection in determining their clearance for sports participation.

  Review our full return-to-play guidelines

• What additional considerations should I make for my teenager or young adult?

  Teenagers and young adults are at a critical point in their life to grow and develop in a variety of areas. The second decade of life presents first experiences with puberty (physical development), self-identity (questioning “Who am I?” and “Where am I going?”), gender identity and sexual orientation, alongside cognitive and emotional and social growth.

  As caregivers decide if returning to school is safe and appropriate, other considerations caregivers should keep in mind include the developmental stage of their unique teenager.

  For some teens, the social and emotional support they receive from friends and interactions with groups helps to shape their identity and strengthen their confidence and mental health. Separation from peer groups and lack of in-person academics might threaten their social, emotional and cognitive wellbeing and development.

  On the other hand, some teens might find the school setting stressful with traumatic episodes of bullying or triggering events. For them, the home may provide a safer space to learn and thrive.

  Caregivers will need to weigh the many complex aspects of their teen (including their medical health) to decide which environment is likely to support their teen’s ability to thrive and develop resiliency.

  Luckily, there are many resources available from national experts to guide caregivers through these decisions and support their teen during these historic times:

  • Centers for Disease Control and Prevention: Teens Back to School
  • UNICEF: Supporting your child’s mental health as they return to school during COVID-19
  • Journal of Adolescent Health: “I'm Kinda Stuck at Home With Unsupportive Parents Right Now”: LGBTQ Youths' Experiences With COVID-19 and the Importance of Online Support
  • Journal of Adolescent Health: Supporting Young Adults to Rise to the Challenge of COVID-19

  Go to the main Adolescents and Young Adult Medicine (AYA) Program page.

• What about children with developmental and behavioral challenges?

  Children with developmental and behavioral challenges encompass a wide spectrum. In the absence of a high-risk medical condition or immune-suppressing medication, return to school in-person may benefit and support them by establishing a consistent routine, opportunities for social interaction, encouraging a sense of normalcy, and reducing burden on caregivers. Return to school ensures an added layer of support physically and mentally as educators ensure children are progressing as individuals. In the event that schools are unable to open for in-person school or need to close during the academic year, advocates will need to encourage added layers of support for children with developmental challenges, special healthcare needs, or disabilities. Caregivers will need to weigh the many complex aspects of return to school decision-making for children in their homes, including consideration of a child’s individual medical needs, the family context and ability to support their child, and the school’s ability to offer a relatively safe space for the child, teacher, and staff.

  View more COVID-19 resources from our Developmental and Behavioral Pediatrics team

• What additional considerations should be made for children in foster or kinship care?

  For children in foster or kinship care, in the absence of a high-risk medical condition or immune-suppressing medication, return to school is likely to benefit and support them.

  Due to their unique health risk factors rooted in trauma history, return to school can promote resilience through establishing a routine promotion of social-emotional health, encourage a sense of normalcy, and reduce burden on caregivers. 

  Return to school ensures an added layer of support physically and mentally as educators ensure children are thriving. In the event that schools are unable to open for in-person school or need to close during the academic year, advocates will need to encourage added layers of support for children in foster and kinship care.

  Caregivers will need to weigh the many complex aspects of return to school decision-making for children in their homes, and there are many resources available to guide these decisions and to support children with trauma symptoms through these challenging times.

  View more COVID-19 resources from our Foster Care team

• What are the benefits of returning to the classroom in person?

  Children benefit greatly from in-person school attendance.

  We recommend reviewing the summary of the recently released (June 2020) “Planning Considerations” from the American Academy of Pediatrics.

• What about increased local spread in our area?

  The local situation of rising cases, hospitalizations, and deaths from COVID-19 is worrisome. Local public health and school officials are tasked with continually assessing the circumstances in our community to determine the safety of in-person school. Consideration of the local case burden is absolutely a relevant factor in each family’s assessment of the risks and benefits of return to in-person school. Students returning to in-person school could increase the community spread and ideally the community would be below the 5% test-positive level before reopening is an option

  This guide should support caregivers and families think through the various factors (community viral levels versus the opportunity, social-emotional growth, developmental support provided by schools) in addition to perhaps one of the most important factors, the risk of COVID-19 on a child’s medical condition or medication that might influence the decision to return to school when that option is available.

• What can my child's school do to keep my child safer?

  The American Academy of Pediatrics (AAP) and the Centers for Disease Control and Prevention (CDC) have outlined some safety procedures for schools to follow.

  • AAP - COVID-19 Considerations: Guidance for School Re-entry
  • CDC - Consideration for Schools

• I have heard that being overweight or obese puts adults at risk for complications of COVID-19. Is the same true for children?

  Although the vast majority of COVID-19 cases in children are mild, most of the early data suggest that obesity, even in children, increases risk that a COVID-19 patient will require hospitalization and/or more severe interventions, such as mechanical ventilation. This risk is even higher in children who have developed obesity-related complications such as type 2 diabetes or high blood pressure.

• Disclaimer

  This webpage content, including any graphics, images, links, text, and all other materials, is provided for general medical educational and informational purposes. The content is not meant to be complete or exhaustive or to be applicable to any individual child’s medical condition.

  This webpage content is not intended to be a substitute for professional medical advice, diagnosis or treatment, and does not constitute medical and/or other professional advice. You should seek advice from your physician or other qualified health care provider with any questions you may have regarding your child’s medical condition.

  We assume no duty to correct or update the content nor resolve or clarify any inconsistent information that may be part of the website. You assume full responsibility for using any information from this website. Children’s Health is not responsible or liable for any claim, loss or damage resulting from your use of the website, including any reliance on its content.