Caregivers of young children need a different kind of mask

By Nicole Letourneau and Mandakini Jain

Everywhere you look, responsible adults are wearing masks in public. This is great news and sure to help contain the deadly contagion COVID-19 from spreading and keep more of our friends, neighbours and community members safe.

Evidence is mounting on the effectiveness of masks with the World Health Organization recommending masks for the general public. Several Canadian cities and provinces have all mandated the use of masks in indoor public spaces and on public transit.

While N95 masks should be de rigeur among health professionals on the front lines of the epidemic, for the public, even homemade cotton masks are helpful to reduce the spread of COVID-19. 

But there’s one group that needs a different kind of mask: caregivers of young children. Caregivers of very young children should avoid wearing standard masks for long hours because it eliminates the child’s ability to read and respond to caregiver facial cues.

Children under three years of age present a special case because their brains are still rapidly developing. According to the Harvard Center on the Developing Child, in the first few years of life, more than one million new neural connections form every second.

These early years are the most active period for establishing neural connections that can last a lifetime. After this period of rapid proliferation, connections are reduced through a process called pruning, which allows brain circuits to become more efficient.

For children under three years of age, their brain development is exquisitely sensitive to social cues — from their caregivers — and most of those cues are in the face. You may have heard of the importance of “serve and return” with young children, the back and forth interactions deemed essential to promote healthy brain development. In infants as young as nine weeks, mothers mirroring infant facial expressions and mothers marking special moments with smiles was found to underpin infant cognitive and social-emotional development.

In the famous “still-face paradigm” in which mothers are asked to keep their faces still for an extended period, infants and young children become very upset, initially trying to engage their mothers, and when that fails to elicit any response, the children typically dissolve into tears and hopeless withdrawal. For toddlers, evidence shows that they monitor their mothers’ smiles to judge whether to try novel activities that are essential to promote brain development and optimal mental health.

Standard masks would eliminate these visible cues for infants and young children and mimic aspects of the still-face.

The younger children are, and the longer they are exposed to blank, expressionless (save the eyes) faces, the more risk to the child’s healthy brain development and mental health over the lifespan. While for older children, more subtle cues such as “smiling eyes” and auditory cues that signal intent may help fill the vacuum, for younger children, exquisitely sensitive to stimuli, brain development is more likely to be negatively impacted.

So, what can be done?

The solution is simple. Members of the deaf community have already offered it — clear masks. Where masks are to be worn in child care settings, caregivers should wear clear masks. Homespun versions have sprung up, however, some are even FDA approved.

Across the country, health authorities have scrambled to develop or adapt policies on mask wearing in childcare settings, but recommendations range widely.

In Quebec, daycare workers in direct contact with children should wear masks when unable to practice physical distancing, impossible with infants and young children. In Alberta, it appears that masks should be worn for prolonged close interactions, and mandatory if groups are larger than 10 or if a child develops symptoms. Toronto Public Health advocates for mask wearing “when necessary,” for example, when providing direct care or consoling a child.

To our knowledge, health authorities have not offered clear guidelines to differentiate the needs of older from younger children. They need to. Quality clear masks need to be demanded, produced, available and prioritized for use by all institutional caregivers of young children.

Without clear masks, childcare settings need funding to ensure that staff are working in environments that follow all public health guidelines to otherwise minimize the use of standard masks with younger children. 

These are challenging times that require innovative solutions. But let’s not forget to address and prevent collateral damage to our littlest citizens. One-size solutions don’t fit all. 

Nicole Letourneau is the Alberta Children’s Hospital Chair in Parent-Infant Mental Health and Professor in the Faculty of Nursing and Cumming School of Medicine at the University of Calgary.

Mandakini Jain is a medical student at the University of Calgary.