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The Masked Kids Are Alright

There are fears that mask-wearing in children will lead to suffocation or developmental delays, but the data we have points to an ill-founded panic

It is easy to raise the spectre of science to scare people. Talk about a new vaccine technology messing with your DNA and you’ve conjured up instant anxiety. It is an especially potent technique when the target of the sciency boogeyman is a child. Children are frequently at the center of moral panics, from video games to heavy metal music, from alleged Satanic ritual abuse to reactionary views on gender expression.

When it comes to masking children during the COVID-19 pandemic—especially when said masking is mandated in schools—a perfect storm is whipped up. The spectre of science can once again be summoned to scare the bejesus out of parents. “Will my child suffocate?” parents start asking. “Will this lead to permanent developmental issues?” Sciency-looking findings can be shared to bolster fears.

Brushing aside the politically motivated fearmongering on the part of bad actors, we are left with reassuring logic, encouraging data, and leftover questions that have no easy answers and no ethical way of being adequately probed. Real-world science can be messy.

Claims of physical harm

A common claim about this issue is the fear that children will suffocate, either from not getting enough oxygen or from a build-up of carbon dioxide (CO2). A scientific review published in 2011 (and thus before COVID) mentions the fact that “a child’s respiratory system is not merely a miniaturization of an adult’s:” children do not breathe as deeply as adults and they take more breaths per minute. Hence, a mask might be fine on an adult but might, in theory, impact a child’s breathing because of these differences. I cannot overstate how much heavy lifting the phrase “in theory” does here.

Luckily, we don’t have to play armchair worrier here: we have data. Public Health Ontario published a synthesis of the evidence we have on mask-wearing in children less than a month ago, and the data they highlight is reassuring. Six studies looked to see if wearing a mask impaired a child’s respiratory function, and there was no objective evidence of this, only reports of subjective complaints. Some kids (like some adults) didn’t like wearing a mask and felt like they couldn’t breathe as well, but when this was measured, there was nothing wrong. There’s even a study that tested three-layer surgical masks in hockey players ages 9-14 and had them simulate a hockey game both on and off the ice, and this study found no effect on their heart rate or in how much oxygen their bodies were getting.

Earloop medical masks and reusable face coverings tend to be loose enough that breathing through them is not a problem. Oxygen and CO2 are small enough molecules that they do not get trapped in the mask: they pass through easily. That study that showed masks were poisoning kids with CO2? It was retracted by its journal, JAMA Pediatrics. The reason? Fundamental concerns about how the study was done, including the misuse of a measuring device. It is bound to become a “zombie paper,” though, a whisper haunting Facebook groups: “There’s a study showing masks poison our children, you know?” A bad paper can travel halfway around the world while its retraction is putting on its shoes.

Even though a child’s respiratory system is not perfectly comparable to an adult’s, we know from adults that masks are not death traps. Surgeons and dentists don’t drop dead from wearing them day in, day out. When the Russian team’s COVID testing results weren’t made available, players on the Canadian women’s hockey team to the Beijing 2022 Winter Olympics agreed to play wearing N95 respirators, which provide a tighter seal and thus more resistance than a medical mask. They won 6-1. As of this writing, none has died of oxygen deficiency or CO2 toxicity.

The other claims of physical harm include the idea that wearing a mask will weaken your child’s immune system. There is no evidence of that. Masks are said to increase illness and deaths, which is a complete canard. In studies of schools with and without a mask mandate, those with the mandate have fewer cases of COVID-19. This benefit cannot solely be attributed to the masks, as other measures are usually in place, but the masks are certainly not making the situation worse. Some have argued that masks are bathing kids’ mouths in microbes, a bugbear that’s meant to trigger disgust, but that is just not true. Again: doctors, nurses, dentists. If microbes are found on the outside surface of a mask, it is not evidence of harm to the child; it is evidence of the mask doing its job. Soiled gloves in the operating room do not imply the surgical staff got infected. It means the protection was necessary.

As for the claim that children wearing a mask will start breathing through their mouth, which will elongate their faces in what has been dubbed “adenoid face” or “long face syndrome,” there is a microscopic grain of truth here. According to the evidence-based medical resource UpToDate, there is limited evidence for chronic mouth-breathing being associated with any effect on the face and mouth during development. Importantly, doctors do not know how long one would have to breathe through one’s mouth for this to have a relevant effect on the shape of one’s face. Let’s also remember that kids are not being asked to wear masks 24/7. Their faces are uncovered while sleeping, at home, outside, and while eating. The odds of a temporary mandate for masking in schools influencing a child’s face are, in my opinion, very, very low.

There is thus little to no merit to the claims of physical harm. What about psychological harm?

Claims of psychological harm

Here, the evidence is not as clear-cut, though it is important to remember that, unlike underwear, masks are not expected to be worn every day for the rest of a child’s life.

Some parents fear that young children will have difficulty recognizing their masked teachers and school staff. This can be mitigated in two ways: being consistent with regards to glasses and hairstyle, for example, and adopting a recognizable, personalized mask or a characteristic item of clothing.

Then there is the issue of emotions. When trying to understand how someone feels, we rely in part on the expression on their face. With half of their face hidden behind a mask, it becomes harder. Some worry that children who are learning to identify emotional information from looking at people’s faces might fall behind. Studies have been done getting children to match a masked or unmasked face to an emotion, and the results are mixed. A couple of studies show the mask adds difficulty; one shows no dramatic impairment, similar to wearing sunglasses; and another one, while using a dark circle that only hides the mouth and leaves more of the face uncovered than a mask, showed no difference for children under the age of 9. It is important to remember, once again, that children still get to practice this skill at home and outdoors, where masks are not used.

Moreover, we do have real-world examples that predate the pandemic. In some cultures, wearing a mask or partially veiling the face is common. As Professor Eva Chen, a developmental psychologist at the Hong Kong University of Science and Technology, told The New York Times in 2020, there is no evidence that children growing up in those cultures are any worse at recognizing faces or emotions. This anxiety, when voiced by certain doctors, seems to come mainly from American and European professionals, as opposed to Asian doctors in whose culture the wearing of a mask to protect against illness or air pollution is more common. And as Canadian psychiatrist Tyler Black told TVOntario, we don’t seem to panic about the wearing of sunglasses around children, even though they also obscure our faces.

Many experts interviewed in the media brought up this key concept of adaptability. Children are plastic. Their development is not easily stunted.

Annoyances and tolerance

With the more dramatic claims out of the way, here’s a lightning round on the annoyances kids report while having to wear a mask and how tolerant they are of having it covering their nose and mouth.

Masks can irritate the skin, true, and four studies report as much, even though they were small and lacked a control group, but a bit of facial moisturizer can help and switching to a different brand of mask may resolve the issue.

Masks can fog up glasses. I personally share this frustration. Washing the lenses with soapy water will do the trick but might distort the view. Taping the mask down on the nose with a Band-Aid or a piece of waterproof tape available in the first aid section of drugstores works really well. It prevents moist air exhaled from the mouth from reaching and condensing on the lenses, and it leaves the mask in perfect condition when removed.

Masks can make it harder to be heard or to hear the teacher, especially if windows are open or air cleaners are turned on in the classroom to improve air quality. This is perhaps the thorniest issue here. Teachers could wear masks with a clear plastic insert in front of the mouth to facilitate lip-reading, but those are reported to fog up very easily and might block sound more than medical masks. Kids can still develop verbal skills at home, watching television, and through remote learning, when teachers don’t have to wear a mask, but in class, muffled speech is an issue. Teachers are often advised to speak louder, enunciate, and gesticulate to better convey emotions, which is an added burden to an already exhausted profession.

Anecdotally, some parents say their kids don’t tolerate wearing a mask. While this may be true, scientific data is encouraging. In most studies of children during COVID-19, over 70% of children wore their masks in the classroom when it was mandated. There is data showing similar adherence by children during SARS, H1N1, and even in studies where children were asked to wear a gas mask or a respirator for upwards of six hours (data summarized here).

Some children are unable or unwilling to wear a mask, or are exempt from it. It might be because they have a severe breathing problem, a major cognitive impairment, or a significant touch sensitivity. This is not an argument for foregoing masks in children; it is an argument for other children to mask up to protect the more vulnerable among them, in much the same way that a vaccine creates a community immunity that allows the people who cannot be vaccinated to benefit from this protection.

Testing parachutes in clinical trials

In that TVOntario interview, Dr. Tyler Black referred to the fears around mask-wearing in kids as “a classic moral panic.” The people feeding it tend to make “absolute statements of inevitable harm,” he said. And what parent wouldn’t want to protect their child from inevitable harm?

We can’t put these fears to rest via a randomized controlled clinical trial in the middle of a pandemic. We can’t force thousands of children to not wear a mask in school and see how many of them end up in the hospital. We can’t withhold masks from every child outside of the clinical trial for years as doctors follow up the kids in the trial to see if, over time, their language skills are affected or if their faces are a tad too elongated when they reach adulthood. It would be unethical. Not everything can be tested by clinical trial.

Yes, vaccines and improved ventilation can be used to protect children instead of masks (to a degree), but no single measure is perfect and adding a mask to these measures can help. Yes, some of the numbers quoted for the effectiveness of mask-wearing in school were from flawed studies, but we should focus on the body of evidence, not on instances when the CDC director quoted a questionable figure. And yes, COVID-19 does not affect children as much as adults and doesn’t kill as many of them, but are we really OK with kids preventatively dying of COVID?

When we read opinion pieces on the subject of children wearing masks in schools, we must be vigilant that their authors are not doing what anti-vaxxers love to do in service of their ideology: overemphasize the harms, real or potential, of the intervention, whether it be masks or vaccines; decrease their benefits in the eye of the reader; and downplay the risks of the disease.

We are two years into a pandemic. Have the fears about children wearing masks materialized? The studies we have so far—and a hefty dose of common sense and low plausibility—say “no.”

Take-home message:
- Masks do not deprive children of oxygen or poison them with an accumulation of carbon dioxide, nor do they weaken their immune system or act as incubators for disease
- The evidence for kids having difficulty identifying emotions on the faces of masked people is mixed, although experience in countries where masking or veiling is common is reassuring
- The biggest issue with mask-wearing in schools may be the muffling of voices


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