Masks 101: A Guide for Children Who are Medically Complex

boy in maskMany states are currently requiring individuals to wear masks in public, including children. In addition, children who are medically complex may want to wear a mask as added protection regardless of state rules or recommendations.

In this article, we will take a look at who should and shouldn’t be wearing a mask, what types of masks to use, how to handle special situations like trachs and hearing aides, and how to properly use a mask.

What is the Purpose of a Mask?

Masks provide an additional layer of protection against infectious diseases that are spread either by coughed or sneezed droplets, as well as airborne infectious diseases. Masks are actually best at protecting OTHERS and not the wearer of the mask. If you happen to be infected, especially if you are asymptomatic, a mask will help to contain any germs you cough or sneeze, as well as those in your saliva or even in the breath you exhale.

Some masks, like surgical masks and especially N95 masks, also filter out infectious particles, protecting the wearer of the mask from infection. Cloth masks will provide some protection from infectious particles as well, though the effectiveness depends on the material, fit, and design of the mask.

In general, we wear masks to protect others, but they may also help to protect us to some degree.

Who Should and Should Not Wear a Mask?

According to the American Academy of Pediatrics (AAP), almost all children should wear a mask, with the following exceptions:

  • Newborns, babies, and toddlers under age 2 should not wear a mask, because they could suffocate.
  • If the available mask is a choking or strangulation hazard for a given child, it should not be worn. This is more likely to affect children with behavioral or developmental conditions.
  • Children with medical conditions, such as those who have difficulty breathing with a mask or those who cannot physically remove a mask, should not wear a mask.
  • Children who are unable to stop touching the mask (or face while wearing a mask) should not wear one, since repeatedly touching the mask or face will increase the risk of infection. Again, this is more likely to affect children with behavioral or developmental conditions, as well as some very young children.
cloth masks

Cloth masks

What Type of Mask Should My Child Wear?

Most children can wear a simple cloth mask, either homemade or purchased online. Once again, the purpose of these masks is to protect others more than the wearer of the mask. The mask acts a barrier to collect your child’s secretions and germs.

The AAP recommends that children who are medically complex and immune compromised attempt to wear a more protective mask, such as a surgical mask or N95, if possible. However, these types of masks are currently challenging to obtain, especially in pediatric sizes. Commercial-grade N95 masks are not small enough to fit the faces of most young children. Surgical masks are disposable and should not be reused repeatedly, so a large quantity must be obtained.

There are a number of masks available online in pediatric sizes that include extra filtration like that found in an approved surgical or N95 mask, but most have not been tested and some may not afford any more extra protection than a cloth mask.

surgical masks

Surgical masks

If your child has or obtains a mask with an exhalation valve or other one-way valve, note that this type of mask will NOT protect others since it emits exhaled air. It is recommended that this type of mask be covered by an additional cloth or surgical mask to protect others.

When Should a Mask be Worn?

Masks should be worn whenever your child is in public and unable to consistently maintain six feet of distance from others. If you are staying at home except for essential tasks, masks are only needed when visiting doctors, going to grocery stores, on public transportation, and in other crowded locations. Masks are not needed at home or in wide-open outdoor spaces.

In areas of the country where you are allowed in more locations, it is still best to keep your child at home as much as possible. Don’t depend on a mask to keep your child safe in a crowded public area.

How Should I Handle the Mask?

Before putting on a mask, wash your hands and wash the mask. Place the mask on your child’s face and ensure that it fits well enough to snugly cover the nose and mouth. If your child is unable to breathe, the material may be too thick or the mask too tight. Make sure BOTH the nose and mouth are covered. The nose must be covered, as germs can be sneezed or blown out of the nose as well as the mouth.

Most importantly, DO NOT TOUCH the mask while your child is wearing it, and instruct your child not to touch it. Touching a mask exposes a person to any germs that have accumulated on the outside of the mask. Not touching the mask can be very hard for many children, and even for adults.

When your child is done wearing the mask, remove it from the back using the bands, without touching the front or cloth parts of the mask. Immediately wash the mask and your hands. If you are unable to wash your mask, bag it in a brown or sealable plastic bag and allow to sit for as long as possible, preferably several days.

Special Circumstances

The following recommendations relate to special situations that may require different mask-wearing techniques.

Children with Ear Abnormalities or Hearing Aides
wrap mask

A mask with two elastic bands that wrap around the head

Children who cannot wear a mask over their ears, whether due to ear abnormalities, hearing aides, or other issues, have many other options. Try a mask with two elastic bands that wraps around the head. Or use a headband or hat with buttons sewn or pinned on either side to hold the mask. Some children may be able to use an ear saver — or even substitute a linking toy — to secure an ear-loop mask’s elastic behind the head.

Children with Trachs

Children with trachs should ideally wear a facemask as well as a secondary cloth covering over their trach, as long as it does not impede their breathing in either location. A bandana-style bib is a good choice for a trach covering. Those who are on ventilators can add filters to their circuits, especially any exhalation limbs or valves, to help protect others. Those who do not use ventilators should consider using an HME with filtration on the trach. Always monitor with a pulse oximeter to make sure the child is able to breathe properly with the coverings in place.

Children with Sensory Issues

Mask-wearing can be very challenging for children with sensory issues. Trying multiple different fabric and securement styles may help you find a product that works better. Securing to a headband, hat, or using an ear saver device helps a lot of children who are irritated by elastic on the ears. Try to limit mask-wearing as much as possible, and be willing to get creative to find solutions that work for your child.

These videos may help provide ideas to improve tolerance:

Children with Developmental and Intellectual Disabilities

Children of all ages with developmental disabilities, as well as young children, may benefit from social stories and other targeted information about mask-wearing. There are numerous options available online, including the following:

Helping children to place a mask on a doll or a stuffed animal may make them more comfortable with the process. Allowing your child to customize a mask and practicing wearing the mask with positive feedback and rewards may help him or her get used to masking.

Children who are Deaf or Deaf-Blind

Children who are deaf or deaf-blind may struggle considerably with communication during pandemics. Those who read lips typically don’t struggle with their own masks, but they are unable to read lips of those around them when faces are covered by masks. It is possible to make or purchase masks specially designed for lip reading, which have a small transparent plastic area sewn over the lips. Ensure that the amount of plastic used does not restrict breathing.

Children who are both deaf and blind may also lose their method of communication, as many use tactile languages that involve touching another person’s hand or mouth (Tadoma method). These methods may become impossible due to gloves and masks.

Note that while most states with masking orders in place have exempted those with medical conditions per the Americans with Disabilities Act, states have not addressed how to handle unmasking of an individual without a disability in order to facilitate communication with those who read lips.

Staying Home is the Best Option

For all children who are medically complex, staying home is still the best option. At home, masks are not necessary unless a family member is sick. Of course, children may need to go to medical appointments and other such things, and this is when a mask should be worn. Nonetheless, staying at home quarantined away from others is the safest place for children who are medically complex.

Author: Susan Agrawal • Date: 5/6/2020
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