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As COVID-19 burns through Texas, districts and health departments across the state are wrestling with how to provide childcare and schooling to the state’s 7 million-plus children. Jerri Barker, who runs a daycare in Waco, has watched warily as other facilities in the area began to report cases of COVID-19 in recent weeks. First, a church daycare, then a community center, two cases here, a few more there.

Although the case counts are easy to understand, not much else is clear.

“Every time there’s a positive case in a childcare, it’s handled a different way,” said Barker, whose facility reopened in May to care for children of essential workers. “They’ll announce that two staff have tested positive on a Friday and clean the center and open back up on Monday, but then other places, staff will test positive and they’ll close for 2 weeks.” After a pause, she added that it seems like “everybody’s just making up the rules as we go along.”

Barker describes the rule book she and colleagues at other centers have received that list the minimum standards for keeping the centers open. “It’s a mixture of what’s already in our regulations, and runs to hundreds of pages,” she said. “Some of it is strengthened [for COVID-19], but most of it is called ‘recommendations,’ and that’s so confusing.”

Between “requirements” and “recommendations,” Barker said, “I am sure there are things I don’t know, but of course, we’re all professionals and we do our best.” She worries about her young charges, her staff, herself, and the school teachers whose children will be in her care when school starts.

As August looms and the start of school approaches nationwide, Barker’s questions are on the minds of parents, teachers, and caregivers alike.

Medscape asked five experts in pediatric infectious disease who consult at the local, state, and national levels about their thoughts on sending children to school and daycare and what best practices might be. Coburn Allen, MD, is associate professor of pediatrics at the University of Texas at the Dell Medical School in Austin. Kristina Bryant, MD, is a pediatric infectious disease specialist with Norton Children’s Hospital in Louisville, Kentucky. Thomas Murray, MD, PhD, is an associate professor in the Yale School of Medicine Department of Pediatrics, Infectious Disease, and Global Health in New Haven, Connecticut. Natasha Nakra, MD, is an associate professor of pediatric infectious disease at the University of California, Davis, Children’s Hospital in Sacramento. Sean O’Leary, MD, is vice chair of the Committee on Infectious Disease for the American Academy of Pediatrics and professor of pediatrics in the sections of pediatric infectious disease and general pediatrics at the University of Colorado Anschutz Medical Campus/Children’s Hospital of Colorado in Aurora.

The five clinicians note that they can only speak regarding the information that is available today and that their views could change as new information emerges. “Two weeks or a month from now, anything could be different,” Murray said. “There’s so much we have to learn, and there’s new information coming out every week.”

Q: What have we learned about pediatric transmission?

Children, especially younger children up to 9 years old, seem less likely than adults to transmit the virus to other children or to adults, say all five specialists. No one yet knows why. It’s possible that children’s smaller lungs do not cough as forcefully as adults’ lungs, so they can’t propel virus-laden droplets as far. Another possibility ― although research on this is mixed ― is that children produce fewer angiotensin-converting enzyme 2 (ACE2) receptors, which are responsible for allowing viral entry into cells. With fewer receptors, fewer viruses would be able to make their way in. Whatever the reason, Allen said, current consensus seems to be that children “don’t seem to get it easily or transmit it well, which is a good thing for schools.”

Among older children, the picture starts to change. Bigger lungs, more forceful coughs, possibly more ACE2 receptors: “Older children, like teenagers, are more apt to behave like adults,” Murray said, and possibly transmit more like them.

On July 18, the Centers for Disease Control and Prevention published findings showing that in South Korea, children younger than 10 do seem to transmit the virus less often than adults and that children from 10 to 19 years old have a more adult-like capacity for transmission. The report added to concerns about school openings. “I think that lesson number one is that children are not a homogeneous group,” Bryant said. “Maybe we can’t think about childcare centers and elementary schools and high schools in the same way in terms of risk.”

Bryant does note that the South Korean results showed that for children of any age, transmission rates among contacts outside the home were really low. The results highlight, she said, that “there’s more to learn about transmission from children, but I do think it’s encouraging that transmission to nonhousehold contacts was so low for both.”

Q: What are the gaps in our knowledge as it relates to childcare and returning to school?

Despite some evidence suggesting that children might not transmit the virus very well, most of the data right now — the South Korea study excepted — come from household studies, Murray says. Schools and daycare settings are still one big question mark. “It’s going to be very interesting to see what happens as school reopens more broadly and there is more child-child contact,” he said.

Allen points to the potential for different modes of transmission depending on age. “We know that kids are probably better at shedding in stool,” he said. That puts increased burden on daycare workers, who should be especially careful and develop best practices for changing diapers.

O’Leary says that so far, success stories with schools are largely from other countries that are in a very different position than the United States: “[T]hey have lower levels of coronavirus in the community [and] better capacity for testing and contact tracing and controlling outbreaks when they do happen,” he said.

“We are still learning about SARS-CoV-2 and its effect on children,” Bryant said. “What we think we know today may not be what we know in October.”

One thing that may become clearer in the fall is whether transmission via surfaces is relevant. In classrooms with small children, Nakra said, surfaces are a “big source of transmission with other respiratory viruses, so it will be important to see what happens there as well.”

Q: In these situations, which is the greatest risk: transmission from child to child, child to adult, adult to child, or adult to adult?

Risk for adult-adult transmission is of highest concern to all of the clinicians interviewed. Indeed, Allen says, adults are usually the source of infection for children, at least within households. And adults, especially those with high-risk medical conditions such as diabetes, are the most vulnerable and the biggest reason for concern, he says. “Right now, for example, in California, there has not been a single COVID death in children, despite 27,000 cases, and that’s what we’ve seen in Texas so far, too.”

In classrooms with younger children, adults may find it challenging to keep children at a distance, Nakra says. Preschool and kindergarten classrooms usually have a lot of hands-on instruction. “Ideally, you would want distance from the children and the children wearing face masks or face shields,” she said, but that’s difficult with children at these ages.

Q: What are the risks for children who are infected with SARS-CoV-2, including long-term outcomes?

“We have data that suggest that children under a year of age may have more severe disease than other children,” Bryant said. She noted that early infancy itself may be a risk factor for more severe infections in general. But, she said, “Most young infants with COVID recover pretty quickly.”

Although many parents might be especially worried about the Kawasaki-like syndrome that has affected a small number of children, it remains quite rare. “The postinfection things are at less than 200 cases right now” in the United States, Allen said. One thing his group is tracking is whether children are showing autoimmune responses after having COVID-19 or testing positive for the virus even if asymptomatic. So far, he said, they are seeing a “lot of things that sound postimmune.” Some clinicians have even anecdotally reported an increase in cases of lupus and rheumatoid arthritis among children who’ve had COVID-19 or who have tested positive for SARS-CoV-2. In many ways, these reports align with the emergence of another inflammatory condition. The postinfection Kawasaki-like syndrome, called multisystem inflammatory syndrome in children, or MIS-C, “sure acts like an autoimmune disease, with a lot of cellular mimicry,” Allen said.

Because no one knows the true rate of infection among children, pinning down the rate of MIS-C is tough, Murray notes. He also says that he’s heard anecdotal reports of lingering breathing problems in children who had more severe COVID-19 symptoms. But he cautions that it will be at least a couple of years before this connection is confirmed. “This virus has now been shown to affect virtually every organ system, so there is absolute potential for long-term complications, but in what age groups is too soon to tell,” he said. For a child with persistent symptoms, he says he’d consider recommending regular evaluations by a pulmonologist.

Q: What are your greatest concerns about child-centered settings, such as schools and daycare centers?

Allen is less worried about children and more about adults, especially those at high risk. “We need to be smart about protecting the right people, those with easily identifiable risk factors,” he said. “We need to do everything we can to spread out chairs and spaces in daycares and schoolrooms and to make it easy for people to say, ‘I am sick, I might be exposed,’ and not risk losing their job.”

Where children are concerned, Allen and Nakra are more worried that not enough are getting vaccinated. “The decreased vaccination rates for the last 6 months has led to a tinderbox,” Allen said. “We are very likely to see a large outbreak of vaccine-preventable diseases,” such as measles. Without well-child visits, Nakra said, “there are concerns for long-term implications.”

Murray agrees. “We need to learn how to function safely in the presence of this virus at some baseline,” he said, and that functioning must include well-child visits for vaccinations. He also brings up the need for child-centered institutions to consider how to keep protections in place for situations such as fire drills or tornado warnings, when social distancing becomes more difficult. That schools have a strategy in place, even for unpredictable events such as these, is “a measure of how thoughtful [their] leadership has been in planning,” he said.

Public health measures to keep children and staff safe will be key, Murray says. These measures should include mask-wearing, being outside as much as possible with appropriate social distancing, and a lot of environmental cleaning. Open windows to allow for air exchange and use of HEPA filters will be important, too, he says. Nakra also emphasizes ventilation and outside time. She said, “We want children masked, if possible,” and acknowledged the difficulty, especially for young children. She has a 5-year-old at summer camp and worries that he’s not wearing his mask all the time.

“Far and away my biggest concern is the abysmal job the US has done at controlling the pandemic in general,” O’Leary said. Getting case numbers down before classes start up in the fall is of “utmost importance,” he said. “If we can get the number of cases down to a manageable level in all 50 states, then school reopening becomes a much more straightforward proposition.”

Q: If you were a parent, would you send your child to school?

“I will encourage my kids to go back to in-person school,” said Allen, whose younger children are in grades 2 and 11. “And as a consultant to several schools and school districts, I am really trying to shift the focus to how to protect our teachers, custodians, and principals,” he continued. Online school “should be avoided as much as possible because I think it really is an equity issue.”

Nakra’s children, ages 5 and 7, have attended summer camp from early June, when rates in their area were low. She says it’s an individual decision for each family. “I’m constantly evaluating my decision,” she said, “but they are spending more of their time outside. If rates continue to go up,” she added, “they will not be there much longer.”

“I believe strongly in the value of in-person education and bringing children together to socialize, especially for younger kids,” said Murray, who has children in middle school, high school, and college. But for that to happen, rates of community transmission need to be “relatively low,” he said. “With high rates, there is a high risk that you’re going to bring people together with disease.” Schools also need to have clear plans for masking, social distancing, and what happens when a teacher or student gets COVID-19. “It needs to be crystal clear and communicated to stakeholders, including parents, so that everybody knows what to expect,” he said.

O’Leary’s children, ages 12 and 16, attend local public schools. He describes himself as “very hopeful” that they’ll go back in the fall. But, he said, “it depends on the epidemiology of the virus…if the transmission is low enough to safely open schools.” In the end, he said, “If the guidance from public health is that it’s safe to reopen school, I would be comfortable sending my kids.”

Bryant’s youngest is in college, and although she doesn’t have to make a decision herself, she is still fielding queries from friends with younger children. Before schools can open, she says, communities must first commit to lowering their COVID-19 case load. “To get to school opening, we have to make certain behavioral choices,” she said, including wearing masks and practicing social distancing to keep rates low. “Having crowded bars…. Is that the best choice if we’re prioritizing school opening? Maybe not.”

Q: More and more districts have committed to online learning in the face of rising case counts. What do you think of that?

“It’s not looking good, is it?” O’Leary noted. “I think in the places where the virus is circulating widely, there is really no choice.”

Murray, too, sees community transmission as an understandable reason for shifting to remote learning. But Allen thinks that the plans should show more flexibility. “School districts making such significant and long-term plans this early, for something changing so rapidly, is a mistake,” he said. “Our kids need to be back in school when it is safe, not some arbitrary period based on fear.”

“Infectious disease physicians and public health officials are trying their best to assimilate the many studies that are emerging every day into public health guidance,” Nakra said. “It’s frustrating for things to be changing, sometimes on a daily basis, but our interests are to protect and maintain the health of communities.”

Currently, families have no choice but to ride the roller coaster. “Quarantine has been very hard on children, and we can’t underestimate the effect on their mental health,” Bryant said. “We can give people the grace to say that families are doing the best that they can.”

Allen, Bryant, Murray, Nakra, and O’Leary have disclosed no relevant financial relationships.

Emily Willingham, PhD, is a science writer and author of Phallacy: Life Lessons from the Animal Penis , to be published in September 2020 by Avery, an imprint of Penguin Publishing Group. Find her on Twitter @ejwillingham.