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Cook Children’s respectfully requests that K-12 schools partner with physicians while opening doors amidst the COVID-19 pandemic. Here's our recommendation.

Public health authorities:

School officials should become familiar with national, regional, and local health authorities who track, trend, and report current states of COVID-19 transmission in communities. The CDC has established three levels of COVID-19 community transmission. i  These levels include: none to minimal, minimal to moderate, and substantial. State, regional, and county health departments, in association with the CDC, should be consulted regarding the current level of local community transmission.

Health education:

All school employees, parents, and students should receive education about COVID-19 transmission as well as the instruction and demonstration of proper hand hygiene and cough etiquette using age appropriate language and materials. Material should be available in English and Spanish. Signage should reinforce education surrounding hand hygiene and cough etiquette. Ample opportunities for hand-washing or use of alcohol-based hand rubs should exist. Teach and remind students to use alcohol-based hand rubs after contacting high-touch surfaces such as door knobs, computers, and devices. Teach students to cough into their elbow rather than their hands. Students should be instructed to try to avoid touching their faces. The impact of healthcare epidemiology, public health systems, emergency management, and supply chain management should be integrated in school curricula to encourage students to examine these careers.

Enhanced environmental hygiene:

Facilities should be cleaned daily with commonly available safe and approved commercial disinfectants. Recommended dry times should be allowed before reuse. Commonly shared computer lab equipment, work stations, and other shared equipment should be wiped down with approved disinfectant and left to dry at the end of each session. Bathrooms, door handles, and all high-touch surfaces should be disinfected regularly.

School schedules:

COVID-19 could resurge at any time. For the purposes of mitigating transmission of COVID-19 from returning travelers, it would be prudent for all schools to follow precautions as if located in a community with sustained transmission of COVID-19, for the first 24 days ii following the return from summer break, a major travel holiday, or major school break.

Improving social distancing by reducing the number of attending school students—such as having students attend school on alternate days— increases hardships for families in which both parents must work outside the home and for single parent families. Large families may have students with misaligned schedules decreasing parent financial productivity. Lack of supervision of teenagers capable of staying home alone may lead to increased teenage high-risk social behaviors, such as vaping and engaging in sex, which leads to increases in vaping-associated lung injury, drug experimentation, teen pregnancy, and truancy.

Some advocate modifying school schedules so that the fall semester concludes at Thanksgiving. The impact of increases in financial hardships for some parents should be considered, if this model is selected.

Ill students:

Ill students should not attend school. School nurses should protect themselves from COVID-19. School nurses should wear paper medical masks and eye protection when evaluating and providing care for students who become ill at school, rather than cloth face coverings. If available, gowns and gloves may provide further protection. Ill students who can tolerate face coverings should wear them if not medically contraindicated. Space permitting, screens should be utilized to separate ill students from one another. Spaces where ill students have been evaluated should be disinfected with approved disinfectants Meticulous hand hygiene should be practiced.

Students with asthma should bring their personal labeled spacer and metered-dose inhalers to school. Nebulization therapy is considered an aerosol generating procedure and should be avoided at school. If nebulization therapy is required, other ill students should be relocated. Nurses should use goggles, wear N-95 masks, gowns, and gloves during nebulization therapy. Ill students who are waiting for parents to arrive should not wait with other students who are well. They should wait in the nurses' office if room or another safe place way from other students.

Policies surrounding illness-related absenteeism should be more lenient during periods of mild to moderate and sustained local COVID-19 transmission due to the established duration of transmission of COVID-19 from sick individuals of up to 10 days after the onset of symptoms. Schools should follow national and state guidance regarding qualifications for the return of students and faculty with possible or confirmed COIVD-19 to the school setting.

Daily temperature screening of students and faculty at school entry has been advocated by some, but variability in accuracy of thermometers exists, which could be problematic. If temperature screening is performed, students should not stand in lines to be screened.

Face coverings:

In communities where COVID-19 transmission is sustained and in situations where social distancing cannot be maintained, all students, visitors, and school employees should wear face coverings on campus and while riding school busses. The contribution of kindergarten and early elementary students to the transmission of COVID-19 has not been well-established. Because expectations for compliance with face cover wearing is understandably low, and language development is crucially important in early elementary students; the wearing of face coverings should be limited to walking in lines in halls and bus riding for younger students. Exemptions for students with developmental delays, autism, and special needs should be examined on an individual basis.

In situations when the risk of burn or injury from the use of a face covering—such as chemistry labs with open flame—face coverings should not be used. Students should not be punished or excluded for failing to wear a face covering properly or at all. However, gentle education regarding the potential asymptomatic transmission from a student who is infected, but feels well, to a family member or another schoolmate, who could get seriously ill, should be encouraged when developmentally appropriate.

A physician note should not be required for a student to attend class either with or without a face covering. Students and faculty should be taught to “TALK LOUDER, DON'T LOWER” masks when communicating directly with one another, as the lowering of masks to communicate in noisy environments has resulted in extensive COVID-19 transmission in industrial settings.


During periods of sustained community transmission of COVID-19, dietary services should prepare and distribute sack or box lunches for students to eat in homerooms or outside unless social distancing can be assured. During these times, if cafeterias can accommodate students in a manner that assures social distancing during meals, students should not stand in lines for lunch service or congregate without face coverings. Drinking from paper cups and personal bottles is preferred over drinking directly from water fountains.

Sports and sporting events: 

During periods of sustained community transmission of COVID-19, athletic neck gaiters iii pulled up to cover the face and nose may reduce transmission among sports competitors in close and direct contact with one another. They should be encouraged unless their use would present an unacceptable injury hazard to the athlete. Cheer squads should designate a single caller with a microphone when practicing and performing.

All athletes should practice hand hygiene when situations allow. Signage should be posted, and students frequently reminded to use sanitary wipes to clean exercise and weight equipment before moving to another station during strength and conditioning training. All dancers should practice social distancing when performing wherever they are. Barres should be cleansed with sanitary wipes after dance classes. Color guards should comply with these recommendations for their practices and regarding shared implements.

Ticket sales for sporting events and performances should be limited to immediate family members of participants. Social distancing of spectators should be encouraged. Sideline staff should be limited to essential personnel. Concessions should be easy to distribute quickly so that concession lines are kept to a minimum. More specific guidance has been offered by the CDC in regard to youth sports, including travel and competitions between teams from different regions. iv


In communities where transmission of COVID-19 is sustained, choir rehearsals should not resume because high rates of transmission have been documented between grouped singers. Indoor wind and brass instrument rehearsals should not resume until more information is available about transmission during the playing of wind and brass instruments. Outdoor wind and brass instrument rehearsals should comply with social distancing recommendations for bands. v Band choreography, drumline, and color guard spacing should take into consideration social distancing recommendations. Students participating in these activities should wear face coverings when unable to maintain social distance and when not performing.

Classroom arrangement, use of large spaces, and assemblies:

Classrooms should be arranged to maximize social distancing. Large spaces, where social distancing can be practiced, should be used for meetings and proctored testing. Microphones should be utilized during question and answer sessions. All assembly content should be broadcast to homerooms.

Distance learning:

On-line school opportunities for immunosuppressed students to learn and immunosuppressed faculty to teach should be increased. On-line accommodations should be examined for students who are quarantined. Preparations should be made for facility closure and an abrupt return to distance learning. Options should be assured for on-campus or alternative site video education for students in home situations that cannot support distance learning. Special education teachers should be proactively engaged to determine how best to include students with special needs in distance learning activities.

Play and social times:

It is important that students play for their physical, social, and psychological development. Wash toys frequently. Wipe down handles on play equipment, swings, and balls with sanitary wipes frequently.


Lack of access to food continues to be a major issue during the COVID-19 pandemic. Parents who have never faced the need for assistance are still learning how to navigate through unemployment and mounting debt. Educate teachers and parents regarding signs that students may be starving. A student who is starving may ask about food frequently, hoard food and snacks to eat later or share with siblings, be inattentive or hyperactive, and have emotional swings. Some may have lost the lustrous appearance and may appear thin. Schools should provide lists of resources for families in need. vi

Emotional and mental health:

Students are dealing with extremes of anxiety, frustration, isolation, and uncertainty during the COVID-19 pandemic. Many students have had obstacles that prevent social and physical outlets to diffuse these. Some are grieving the loss of family, friends, and an accustomed way of life. Students may act out, withdraw, show diminishing school performance, have uncharacteristic emotional displays of anger and frustration, or try to self-medicate when experiencing depression and anxiety. Increase staffing to provide emotional and mental health support to students. Screen frequently and proactively for signs of depression and suicidal ideation.

Child maltreatment:

During these extremely difficult times of isolation, financial strain, insufficient resources, and parental exhaustion; child maltreatment has reached epidemic proportions.  Report any concerns for child maltreatment to appropriate authorities and immediately refer students for evaluation and treatment.

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Development of the recommendations: The enclosed recommendations were initially drafted by the Epidemiologist and Medical Director of Infection Prevention for Cook Children's. They were presented for initial review to other members of Cook Children's Department of Infectious Diseases who have become subject matter experts regarding COVID-19 through intense study, participation in educational activities provided by the CDC, vii IDSA, viii SHEA, iv and other stakeholder organizations; and by participating in preparedness activities and clinical care of hospitalized victims of the pandemic. These recommendations were then presented in an email open forum to all physicians in our network, who were encouraged to comment and enrich the recommendations with the full measure of our broad experience in general and subspecialty pediatric, developmental, behavioral, mental health, child maltreatment issues, and the special barriers facing impoverished children. Over fifty physicians helped to add additional thought, revision, and content to the recommendations.

i CDC. Implementation of Mitigation Strategies for Communities with Local COVID-19 Transmission, Table 3. Potential mitigation strategies for public health functions. March 12, 2020.

ii Twenty-four days includes an incubation period of up to 14 days to develop infection and up to 10 days beyond that to spread infectious virus either symptomatically or asymptomatically.

iii Neck gaiter face coverings are collar-like, cylindrical, form-fitting neck garments that can be pulled up to cover the mouth and nose.

v COVID-19 Summer Marching Band Practices & Rehearsals. UIL.

vi Assistance finding a variety of services is available through the Department of Texas Health and Humans Services.

vii Center for Disease Control

viii Infectious Disease Society of America

ix Society of Healthcare Epidemiology of America