Mask on, Mask off: The Role of Comprehensive Craniofacial Care in Addressing Patient Safety and COVID-19 Mandates during School Reopening

As coronavirus disease of 2019 transmission persists across the United States, mask wearing has become a primary tool of public health containment efforts. In order to slow transmission of the virus, state and local governments are increasingly introducing mandatory mask orders. While backed by public health evidence, these mandates have presented challenges for certain individuals, including children with cleft and congenital craniofacial differences.

In Ohio, for example, it is mandatory for students in grades kindergarten through 12 who have chosen to attend in-person class to wear masks. When making masking policies, public health officials and lawmakers should consider special groups, among whom wearing masks presents potential safety concerns.¹ In response to Ohio’s statewide mask order in July of 2020, local medical society chapters led efforts to exempt from mask orders children younger than 2 years old, children unable to remove masks without assistance, children with psychiatric conditions that can be exacerbated by the use of a facial covering, and children with facial deformities that cause airway obstruction.² Similar concerns have likewise been reported in the United Kingdom.³

While mask mandate exceptions may adequately accommodate children at an individual level, they simultaneously may confer a systems-level dilemma affecting schools, teachers, parents, and children alike. Logical responses from schools may include encouraging virtual rather than in-person education plans for mask-exempt children or distancing cohorts of unmasked children from their peers. Such well-intended efforts may, however, exacerbate the psychosocial challenges of children with craniofacial differences, such as attention deficit disorder, anxiety, and attachment disorder. The social isolation of those with facial differences is likely further compounded by social peer pressures or “mask shaming.” Not wearing a mask may be socially ostracizing, and mental health teams should help children prepare for questions that will arise for those who have medical exemptions. In addition, virtual platforms may be inadequate to deliver programs crucial for comprehensive cleft care, such as speech therapy. As schools commence nationally, school boards and administrators must anticipate the needs of at-risk patients in order to maximize academic achievement and functional development.

These issues highlight the importance of the interdisciplinary cleft-craniofacial team in patient advocacy as well as in clinical care. It is critical that parents and craniofacial caregivers educate teachers and school leadership about the potential for adverse sequelae. Teams may consider proactive outreach to patients to screen for these concerns, to provide letters of exemption from mask-wearing, to provide counselling and behavioral therapy given the increased social pressure, and to provide speech therapy given the loss of school-based provisions. Additional efforts should include encouraging parents in modeling mask wearing and being mindful of the way they talk about masks, children practicing mask wearing outside of school in order to prepare for school, and parents and caregivers using praise and positive reinforcement for children who are having difficulty with adhering to mask wearing. Without these active interventions to overcome barriers preventing the continuation of prepandemic routines, we risk a pandemic of devastating setbacks at annual follow-up visits.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.

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