Earlier this summer, American families looking forward to the school year were experiencing something unfamiliar: Hope. Might school be “normal” in the fall? Would kids even need to wear masks? Sure, we might technically still be in a pandemic, but times had started to feel, well, precedented.
Now, the Delta variant has arrived to remind us that we are very much still in this thing. Millions of kids under 12 aren’t eligible for vaccination, and breakthrough cases are if not common, at least not unheard of. The ongoing pandemic is going to require continued flexibility and managed expectations for parents and employers.
Case in point: How are we going to treat kids with cold symptoms in the Covid age?
Way back in 2020, when schools and daycare centers reopened after the strictest phase of lockdown, many beefed up their illness policies to reassure worried parents and staff that schools were safe places to be. In addition to requiring quarantines (which cause their own logistical headaches) after possible exposure, administrators required that children showing any Covid-19 symptoms stay home until the disease was ruled out by a negative test (or a full 10-day period passed).
Absences from work because of childcare disruptions skyrocketed in the pandemic.
However, the symptoms of Covid-19 overlap with so many other childhood illnesses that it can be hard to distinguish between them, a fact even the CDC acknowledges. A side effect of this process was that children’s minor ailments — the ones they regularly attended school and daycare with in the past — were presumed to be Covid-19 until proven otherwise, requiring more tests and longer waiting periods after symptoms resolved. It was simultaneously easier to be sent home for symptomatic illness and harder to return after experiencing colds, coughs, or quickly-resolving fevers.
Earlier in the pandemic, such caution was understandable. And fortunately, widespread mask wearing in schools prevented colds in addition to Covid-19, avoiding some of the trade-offs these strict illness policies incurred. But going forward, especially in areas with low transmission of Covid-19, conservative illness policies have the potential to disrupt learning and childcare with much lower benefits in return.
The Season of Runny Noses & Low Fevers
Two symptoms in particular illustrate these dynamics: runny noses and fevers. The Centers for Disease Control and Prevention lists both as possible symptoms of COVID-19, though they are of course, also symptoms of many other ailments.
Depending on the school or childcare setting, a runny nose on its own is enough to exclude a child and require a negative Covid-19 test, and sometimes a doctor’s note, to return. Such situations are likely to become common as people – and our germs – resume mingling. Indeed, this has been a terrible season for summer colds. And we know already that young children in childcare get sick several times a year, to such a degree that it’s termed “daycareitis.”
Fevers too have been treated differently during the pandemic. Children have never been allowed to attend school or childcare with a fever, and they shouldn’t be. However, some daycares and school districts have lowered the cutoffs for what temperature constitutes a fever to 99.9 or 100.0 (like New York has done), when traditionally it was 100.4 (the CDC still uses the 100.4 cutoff). Children can come back once they’re fever-free for 24 hours without medication, provided they also have a negative PCR test for Covid-19. Though in some cases, the post-fever waiting period has increased to up to 72 hours.
In essence, fevers related to teething or after a routine immunization could sideline kids and their parents for multiple days.
Unstable Childcare Complicates Work For Parents
The inconvenience of unnecessarily strict illness policies can add up to significant disruptions for working caregivers. Sick kids often need parents to stay home to care for them, potentially complicating return-to-office mandates slated for the fall. Getting a PCR test requires time off work and a wait for results. The testing backlogs that plagued the nation last year have mostly eased, though a check of several clinic locations came with a warning that results for a molecular test could take one to four days to arrive. In addition, siblings and household members of people exhibiting any Covid-19 symptom (or awaiting a test result) may also be required to stay home from school and childcare until it’s resolved.
Absences from work because of childcare disruptions skyrocketed in the pandemic, according to research from the Center for American Progress. Parents of children under five fared the worst, and many who stayed employed passed up promotions or reduced their working hours to compensate for unstable childcare.
Minimizing disruptions to school and childcare is critical for working parents, says Dr. Monica Gandhi, an infectious disease specialist who teaches at the University of California, San Francisco. We’ve lowered the bar for what it means for a child to be sick, and that has ripple effects.
“We have always allowed children with slight runny noses to be in school, especially if they don't have Covid,” Dr. Gandhi says. Wearing masks further reduces the chances of a child passing on an infection.
Exclude Less Often, Return Faster
Unnecessary exclusions from childcare were a problem before the pandemic. Roughly a third of parents in one study reported going to an emergency room or urgent care to get their child evaluated because they needed a doctor’s note to return to care. Pediatrician Kelly Fradin, who runs the popular Instagram account AdviceIGiveMyFriends and is the author of Parenting in a Pandemic, says the pressure on medical practices from unnecessary note requirements is a real concern.
Speaking last fall, Dr. Fradin said pediatricians were worried about note requests during a time they were trying to keep their waiting rooms free for other, more serious needs.
The only definitive way to know whether a runny nose or low-grade fever is Covud-19 is to test for it. Being able to rule it out with a test is an accomplishment in itself, said Dr. Gandhi, noting that many other childhood diseases lack diagnostic tests. And Dr. Fradin said in an email that it’s reasonable to require ruling out Covid-19 before returning to school, inconvenient though it may be.
Dr. Gandhi recommends that schools and childcare centers allow parents to use rapid antigen tests to rule out Covid-19 instead of requiring molecular tests. Over-the-counter rapid tests like the BinaxNOW by Abbott are available at many drugstores, but they’re not exactly cheap and families may need them regularly. They’re less sensitive than a molecular test, but also less likely to lead to false positives, which is a real concern in areas with very low transmission.
Indeed, national daycare chain Bright Horizons doesn’t exclude kids from care if they have the sniffles. The company’s Covid-19 policy also uses the 100.4 degrees Fahrenheit threshold for a fever, but does require a negative Covid-19 test in order to return before ten days.
Lots of Questions, Few Answers
The tradeoffs that school districts and childcare centers make have enormous consequences for consistent school attendance. Extra caution may be needed in the face of Delta, but it won’t come without a cost. Anyone who relies on school and childcare for their kids, especially employers of caregivers, would be wise to pay attention.
Colds are more common in very young children who don’t yet have schoolwork to make up. School-age kids are more likely to be affected by quarantines and classroom closure, which some districts are still deciding how to handle. There will need to be a protocol for making up assignments and classifying absences, especially if there’s no remote option to easily fall back on. Employers may need to maintain flexible work policies and sick time to accommodate childcare and schools’ continued instability.
The fast-evolving nature of the pandemic presents another thorny challenge for school districts and other organizations, Dr. Fradin said recently. They must pick a benchmark — of symptoms or cases per classroom — that will trigger exclusions or closures and it’s hard to revise it later if things change. They might choose to err on the side of caution in case the situation gets bad. But doing so will leave parents on the hook for the disruptions that have been designed into the system.
Ultimately, the best way to reduce the need for strict illness policies is through widespread vaccination, which drastically lowers the chances of coming down with Covid-19. Vaccinated people are already subject to less stringent quarantine and testing requirements. In short, it makes it easier to assume a cold is just a cold.
"This is a very complicated pandemic moment," says Brown economist Emily Oster, who has advocated for prioritizing in-person school during the pandemic. At some point, perhaps not right now, she says, we’ll need to move from attempting to eradicate Covid-19 to learning to live with it, and that will require re-evaluating the costs and benefits of our policy decisions.
Benchmarking illness policies or other mitigation measures to local rates of hospitalization or transmission could provide needed off-ramps to pandemic vigilance. Eventually, there will come a time when prevention of Covid-19 transmission won’t outweigh the learning disruptions it causes. But we’re not there yet, which means continuing to plan for pandemic pandemonium.
Dr. Monica Gandhi, Professor of Medicine and Associate Division Chief of the Division of HIV, Infectious Diseases, and Global Medicine at UCSF/San Francisco General Hospital.
Dr. Kelly Fradin, Pediatrician
Emily Oster, Professor of Economics at Brown University and the author of Expecting Better, Cribsheet and The Family Firm