Understand the WHO Guidance on Children and Masks: Q&A With Dr. April Baller

Last week, the World Health Organization published new guidance on children and masks, suggesting that children under the age of 5 should not wear masks. To learn more about this recommendation—and what to do if this suggestion contradicts local guidance—Every Woman Every Child spoke with Dr. April Baller, a WHO infection control expert. This interview has been lightly edited for clarity.

Why did the WHO decide on 5 as the age when children must start wearing masks?

[The decision] was linked to the principle of “do no harm.” It was linked to dexterity: how well they’d be able to tie the mask and how long they’d be able to keep it on, and would they touch it too much and make it more of a source of infection? The other thing around design is obviously the fit. Children tend to have the nasal ridges a bit lower, so the masks don’t always fit so well. Looking at all those different areas was very informative. 

Children tend to have different milestones at different ages, and by the age of five they can tie their own shoelaces. That is a proxy for them being able to tie the mask. And also [by five] they have a good understanding about not touching it too much. It’s one thing to put on the mask, another thing to keep it on. Some of the data that was looked at showed that some children were actually okay with putting it on, but for them to keep it on was very difficult. That was also taken into consideration. 

The WHO guidance differs from other guidance. For instance, the US CDC states that children over 2 should wear a mask. What is your advice for parents who may be confused by the discrepancy?

WHO is an organization giving advice to policymakers and decision-makers at a high level. It’s up to every country to then adopt and adapt those guidances. In local contexts, there can be very different types of transmission, not just within one country but within one state. So there could potentially be some differences. And that’s also why we say it’s a risk-based approach because what’s right in one country is very different from another and there will be those discrepancies. As an individual, the first place people should go is to their local government to see what the policies are. 

Can you provide some insight into the process of issuing this guidance? 

It was actually quite a long process. It starts with this specific area in which we’re working, which is infection prevention control (IPC). We have a group of over 30 experts that meet on a regular basis and discuss any themes there are and look at the evidence and really come to consensus. 

This is probably the tenth guidance that has come out from this group over the last eight to nine months. There was an evidence review, done by the WHO Scientific Committee, which looked at the evidence on the transmission in children and also looked at the use of masks and children. That was presented to the IPC GDG (guideline development group), and there were also discussions and meetings with UNICEF, who is a co-lead, and with the International Pediatric Association. It was a consensus-building process which started in June and went on through July and August. Eventually, once the guidance was drafted, it was also shared with some external experts. 

What kinds of research did these experts look at? 

There was two main areas that we looked at. One is around transmission in children. What is the percentage of children that are getting infected with COVID? What is their vulnerability and susceptibility? Where’s that transmission happening? That means looking at the different settings, and obviously critical to that is the school settings. The trend seems to be that transmission is linked to social interactions, which tends to happen [more] as the children grow older and have more and different types of interaction groups. That was a trend that tends to increase as they grow into teenagers and young adults.

The other area was looking at the effect of the use of masks. We looked at influenza as a proxy and for indirect evidence, and there seemed to be some evidence [for masks being helpful]. However, there were issues around compliance and around fit. One thing that has come out of this is the real need for some implementation research. This guidance are now being adopted in countries and school settings and I hope that some of this [implementation] research will be done to better inform future guidances.

Is there anything else that’s important to know in this discussion around children and masks?

It’s important to reiterate that masks are a tool and part of a comprehensive package. There’s quite a lot of focus  on masks, and that is a positive thing, but on its own, masks can’t solve all the issues. That’s why it’s critical to maintain physical distance and do the hand-washing too.