Last week, I did an AMA here in conjunction with the release of The Family Firm, and I think the mood is well summarized by the screenshot below.
As parents, I think it feels to many of us like we are back in April or May of 2020. Especially when it comes to child care and schools. We were ready to go back, planning to go back. Should that change?
Today’s newsletter is long, because these choices are hard and confusing, and I want to give you enough information to try to make them.
First: I’m going to talk briefly about the Delta variant and what is new (and what’s not).
Second: I’m going to put up some numbers for risks to kids if they get COVID-19. You’ve heard, presumably, that COVID infection in children is low risk. What, precisely, does that mean?
Third: I’ll talk through the day care and school choice now, using a version of the Four F framework (which, not coincidentally, is very similar to the framework from the May 2020 Grandparents and Day Care newsletter). I will not have answers, but I have a few new thoughts on how you might think about it.
Before we get cracking, two things.
I want to be clear up front this particular newsletter is focused on personal decisions. There are active policy debates about schools and child care and masks and mandates and vaccines. But for individual parents, we are making choices under the set of constraints we have in the community we live in. We can advocate for universal masking in schools, but we may also have to decide whether to send our children to schools where not everyone is required to mask. This newsletter is about that second kind of question.
I also want to be clear that the best way we can protect kids under 12 right now is through the vaccination of adults around them. This cannot be emphasized enough.
Delta: What Do We Know?
The CDC messaging on Delta and masks has been extremely confusing; a good summary of this confusion is here. Part of the issue (but not all of it) is that the data is still evolving. What do we know?
Three things are clear: (1) the Delta variant is more contagious; (2) breakthrough infections are possible, more so with Delta than other strains; (3) vaccines are the best way to protect yourself and those around you.
Where the most confusion lies, I think, is in the frequency of breakthrough infection and in the question of transmission from vaccinated people. On the one hand, it seems clear that vaccinated people are less likely to transmit (due to less infection and lower viral loads). On the other hand, it also seems clear that vaccinated people can transmit to some extent and and yet concrete numbers are lacking.
And for questions like: What is the risk of me transmitting to my child if I go to a wedding? What if I wear a mask? We just simply do not know.
This not knowing is a bit paralyzing. But in terms of your own behavior, I think this really boils down to two things you can actually do (other than get vaccinated). Be more careful—more masks—when in indoor settings. Re-evaluating events like weddings, depending in part on how important they are to you. And if you feel sick, get a COVID test and wait for the results, even if you think it’s probably just a normal cold. (I would suggest getting some rapid antigen tests to have at home).
If your whole household is made up of healthy, vaccinated people, then you should feel protected, and taking these precautions is a good idea and probably enough. (If your household contains older, immune-compromised people, I think this all gets a bit more complex, but I’m not going to talk that through today.)
If you have unvaccinated kids, read on.
What Do We Mean by “Kids Are Low Risk”?
You have heard, presumably, that healthy kids are low-risk for serious illness. See, for example, the below quote in the New York Times this weekend.
But this feels abstract: what does it really mean?
To discuss this, I think we have to start by saying: Imagine your child actually gets COVID-19. What should you expect?
First, there is about a 50% chance they’ll be totally asymptomatic (based on various things, including this French study). If they do have symptoms, in the vast majority of cases, those will be mild and short term. Last week, The Lancet published this excellent study on about 1700 symptomatic COVID-19 cases in children. The most common symptoms were headache and fatigue, and the average duration of symptoms was 6 days, with 75% of children having symptoms for a week or less.
But what about serious outcomes or long-term symptoms? I’ve created a table below, looking at long-term symptoms and both hospitalization and death risks. There is a long source document on creating this table here, so look there for details. I’ll also keep that as updated as possible going forward.
(I know you wish this was separated into smaller age groups; me too. Data is just not there for that. And all of these numbers are very rough and evolving.)
These figures represent averages; the risks are higher for children with serious preexisting conditions, and lower for healthy children. They also tend to be higher for older children than younger. It’s also the case that children of color are disproportionately represented in severe outcomes, although it’s unclear whether this reflects more susceptibility to severe disease or simply higher case rates. As the authors of the paper on mortality note, the risks in all groups of children are extremely low.
It’s more challenging to find numbers on long-term symptoms of the flu, but it’s important to note that long-term illness from flu or RSV is not uncommon, so COVID is not alone there.
The million dollar question: Does Delta change this? It is not completely clear. People, including the CDC Director, have cited more hospitalizations among children in heavily affected areas as evidence that Delta might be worse for kids. However, with more cases, we expect more hospitalizations. We saw this rise in pediatric hospitalizations last winter, as well, without Delta. Seeing more cases is different from saying that delta increases the hospitalization rate. There is also an increase in RSV in young children in many of the same areas COVID is spreading widely, complicating the analysis.
I would argue, though, that what we do know suggests the risks are in the same range. That the narrative that this is a new virus which is tremendously more dangerous for children is just simply not supported by the data.
For example: In the data from the UK, the risks of hospitalization are similar for children during the Delta wave as during previous ones. And the AAP data shows fairly consistent hospitalization rates over time. Finally, we aren’t seeing a significant increase in the number of pediatric hospitalizations in areas with high vaccination rates for adults, which is also encouraging.
It could be that Delta is moderately more serious for children, but it is not clear. We need more data for this to be precise. I hope the CDC is collecting it, quickly.
In summary, what does one take from this? When kids get COVID-19, the vast majority of the time you will either not know, or they will have a mild cold-type illness. They can, however, get seriously ill.
None of this is to downplay COVID or up-play it, or any-play it. Kids can get COVID, for sure. A small number of kids do get seriously ill; the risks from serious illness are significantly higher than a common cold or stomach flu. But as hard as it is to acknowledge, the risks are in the range of risks that are inherent in our lives. Any death of a child is an unbelievable tragedy, but we do live with choices that take these risks, whether we acknowledge them directly or not.
How Do I Approach School and Child Care, Now?
We turn now to the question at hand, to decisions that are under our control. How do we think, now, about school and child care? Deliberately, of course.
Frame the Question
What choices do you actually have? This is likely to depend a lot on whether you’re talking about child care or school. For those parents thinking about child care for a younger kid, the choice is probably child care/preschool versus a nanny or parent. There may be multiple child care options.
For those of us with school-aged kids, the choice may be more constrained. In some cases, there is a choice to continue to opt for remote school. In others, there is not. You could agree or disagree with the option to provide remote school, but we make our choices in a constrained environment. Without a remote option from your school district, the other options (homeschool, for example) are more burdensome and may be infeasible (or maybe they’re not!).
As you think this through, there may be sub-choices. If you are in a district or school without a mask mandate, there is a choice of whether to send your child to school masked, unmasked, or (maybe) not at all. So those are three options.
You may simply have limited choices here and as frustrating as that is, it may be useful to recognize it and be able to focus on what you can control.
In The Family Firm I call this fact finding; in the COVID context, the facts are mostly about risk.
There are two components to thinking through risk. The first is mitigating risk — basically, whatever choices you make, how can you make them as low risk as possible? In the case of COVID and schools or child care, the CDC has guidance (accessible here). To the extent you can push your schools or child care towards it — towards more vaccines, possible testing, ventilation, and masking — it is a way to mitigate risk. And even if your school doesn’t require masks, you can put your kid in a good one (N-95, KN-95). You can get rapid antigen tests for home and test your kid even if the school isn’t.
The bottom line, though, is that the risks of schools and child care are mostly out of our control. This may be frustrating, it may make us so very angry. We may all be very, very mad at Ron DeSantis for making this all harder. But that isn’t decision-relevant. The policies are what they are, and we make our decisions in the face of them. (Also, what is in your control is getting vaccinated which is the best way to protect your kids.)
The second risk step is to evaluate risk. How risky is in-person schooling? I started, above, by showing you some concrete numbers on what people mean when they say “kids are at low risk for serious illness.” Those numbers are what they are. But how to use that in decision making?
I think part of what is making it hard to move forward is there are so many sources of uncertainty — risk of transmission, risk of other people having it, risk of serious illness. We’re moving them all around in our head together and it’s too much. We need a way to simplify our thought process.
I’m going to suggest a bounding approach where you try to solve the problem under different assumptions about just one element. Namely, the risk of your child getting COVID.
Start your decision by asking: What would I do about this choice (school, child care, something else) if I knew my kid was completely protected from COVID? (They’re not! It’s a thought exercise). In a sense, this may seem obvious. Of course I’d send them to school!
But wait. For many people I speak to about child care, a big issue for them is disruption. Even if your kid is in a COVID shield bubble, other kids are not. If the child care quarantine rules are such that you’ll be constantly out for exposures, it may be infeasible to go to school even if your kid will never get COVID.
On the school side, for some kids, remote learning worked better (see this tweet, for example). I’d venture it’s not common, but for some kids this may be a better choice. In that case, you might want this option even without the COVID risk.
Answering this question could, in some cases, mean you are done.
But let’s imagine that you would send your child if there were no risk to them. Now, let’s think about the other, harder bound. It’s nerve-wracking to even ask this part of the question since, as parents, we simply do not want to think about our kids getting sick or injured. But facing this directly will help us make choices.
What would you do if you knew your child had, say, a 20% chance of getting COVID-19 at school or child care? (Again, this isn’t a reflection of reality, it’s a thought experiment.) Would you send them? What if it was 50%? 80% 10%?
This is hard to think about because the knee-jerk reaction to seeing even a 20% of risk of COVID may be along the lines of “Of course, I would never subject my child to that kind of risk.” We’ve been thinking about the risks of getting COVID for kids as, basically, very very small. We’re trying to reduce them as much as possible with precautions. And yet, this small-ness is part of what makes it hard to think about. A 20% risk is something you can understand. And for this reason, I think it is worth sitting with this question for a moment.
There are good reasons to send your child to school or child care. Their learning. Their mental health. Your family functioning. I posted this perspective from a friend running a summer camp on Medium this weekend. Someone told me recently that the outdoor camp her child is engaged with has returned him to his pre-pandemic self. This is important, too.
So I would suggest you sit with this thought experiment, and try to come to some cutoff. Where might you draw the line? The value of thinking about it this way is you are drawing the line around something that at least you understand. You can think about this risk alone, rather than trying to multiply it by everything else.
There is no right answer to this question. You could compare to some familiar risks. The actual share of children who get flu in a given year is around 20%, for example. Most of us assumed that risk annually in a pre-COVID world.
For some people, the answer may simply be: There is no COVID risk that I would be comfortable with. And that is a really useful thing to know, because it should shape your decisions.
I would urge you to try to develop this benchmark even before thinking about the actual risks in schools or child care. The point of this exercise is to try to isolate your risk tolerance from these detailed calculations about risk in a particular activity.
Then, of course, we can ask what is the actual risk of getting COVID at school or child care? It’s not possible to answer this with certainty, which is part of the problem, and most of our data comes from pre-Delta. The data we do have, though, suggest very low risks. Some examples…
- In Rhode Island last summer, a dataset covering 666 open child care centers with spaces for 18,000 children found only four instances with possible within-center spread.
- A study in New York schools last year, published in the Journal of Pediatrics, found overall low rates of COVID-19 in routine school testing. Among 36,000 people quarantined based on a close in-school contact, only 0.5% of them tested positive for COVID-19.
- Data from North Carolina, covering 90,000 students and staff, found 32 instances of probable in-school transmission over a period of 9 weeks.
Again, we cannot know for sure how Delta will change these numbers. Delta is more contagious, but these numbers are also from a period without vaccines. Even some level of vaccination among adults and older children will be protective.
Our most significant post-Delta data comes from the UK, where the positive test rate for children up to age 11 was around 2% at the height of the Delta surge, when schools were open (largely without masks). This 2%, of course, reflects transmission from all sources — schools, but also households. Repeat: Household transmission is a much more common vector for children, meaning vaccinating people in the household is your most important prevention strategy.
Final Decision & Follow-Up
I’m advocating an approach here which, basically, amounts to a way to think about quantifying your own risk tolerance in deciding about in-person school or child care. Depending on where you come down on this, your decision may be easier or harder. If you decide a 20% risk of COVID for your child is worth in-person schooling or child care, then it very likely makes sense to send your child given what we know about in-school transmission.
The fact is that even in a location with lower rates of vaccines and where masks are not required, nothing we have seen in any data from anywhere would suggest anything like a 20% risk of transmission to children at school or child care.
If you’re at 1%, then this decision is more complicated. However hard it is, though, try to make a decision and move forward.
There is a space for follow-up here, but I think it’s a mistake to have some kind of daily re-obsession about the entire thing. In these decision discussions you may come to some cutoff, and this may suggest a particular re-evaluation approach. But this should be quick — a cutoff number to re-evaluate, not a plan to re-evaluate the re-evaluation plan every day.
Two Final Notes
(If you got here!)
First: if you do choose to send your child to school or child care, it is worth being prepared for the fact that the first days will be anxiety-provoking. Probably even if you sent them last year but especially if you didn’t. That’s expected, it’s normal, and it doesn’t mean you made the wrong choice.
Second: I know some people will react to this whole idea by saying it’s downplaying risks, that by suggesting people might send their child to school even if they knew there was a non-trivial chance they’d get COVID, I’m suggesting we should be cavalier. I’m not, obviously, and this is a personal thought experiment not a policy suggestion.
However, it is important to note that when policy makers tell people, “Kids are low risk so you should feel comfortable with school/child care/etc” they are implicitly allowing for the possibility that kids will get COVID. Our messaging of late has seemed to say this on one hand, and on the other hand convey that we should now be very, very afraid for children.
This isn’t fair. Parents need to be able to make decisions, and to move forward. And for that, they need facts.