Last week, a study in JAMA Department of Pediatrics create destruction. The study took 45 children (ages 6 to 17) and asked them to wear a mask. It measures the rate of CO2 inside the mask. This rate is high and inversely proportional to age: the youngest children seem to have the highest CO22 concentration.

Criticism came immediately. One attentive observer indicates that when children breathe in, only a small fraction is coming from inside the mask (where higher CO levels are possible).2 level). The rest of the air is drawn through the mask, and the CO2 will be diluted with room air in the lungs. There have been more objections raised (some legitimate), and the usual calls for a retraction.

However, both the newspaper and the critics missed the point: Should children wear masks and if so, when?

It’s a simple question, but it divides public health authorities. The World Health Organization (WHO) recommends that children under 5 years old should not wear masks and only wear masks for children aged 6 to 11 years old in some cases. The CDC advises any unvaccinated individual over 2 years of age to wear a mask in public indoor spaces. This means that WHO and CDC are completely opposed to the decision to cover the face for children aged 2 to 4 years in daycares or other public settings. Who’s right?

The truth is that there are potential benefits to children wearing masks and potential risks. The greatest potential benefit is a reduced ability to acquire and transmit SARS-CoV-2. Potential risks include concerns about normal language acquisition, speech, and development. At a very young age (<2 years) or during sleep, there may be a risk of suffocation, both the CDC and WHO acknowledge.

Real life can be complicated with both benefits and risks. Young children may not wear a suitable mask and it may slip off their nose. Saliva or mucus can leach into the cloth mask, which could reduce the benefits of wearing a mask and potentially increase the risks. Under heavy physical exertion, masking children may lead to fatigue or a subjective feeling of dyspnea.

On balance, do masked kids help?

Before I answer the question, let’s consider one more complication: It may not have a single answer. Here are some factors that may determine the answer:

  1. Mask type: cloth vs disposable surgery
  2. Child’s age/executive function: Under some age or some self-control, the mask may not work hypothetically
  3. Indoor and outdoor: At this time, nearly all authorities advise against wearing masks outdoors
  4. Rate of SARS-CoV-2 in the community: Masks can be beneficial if community cases are above a certain threshold (e.g. 10-100 per 100,000), but in theory could have real harmful effects at a low rate. when the virus barely circulates
  5. Time spent indoors: The mask could hypothetically work on children in the classroom for 15 minutes or 2 hours, but all the air could be exchanged for 8 hours with each other in one room (depending on ventilation) and they are not “active” during this time
  6. Cohort group: If the children are in a cohort together, wearing a mask may be superfluous, during the usual long school days.

Here’s the real answer to the question of whether it’s worth wearing masks for children: No one has any clues. For the past year and a half, the scientific community has failed to answer these questions. Not completely. We don’t know if the mask is suitable for children 2 years of age and older, 5 years of age and older, 12 years of age and older. No idea if they only work for a period of time. No idea if this is linked to community rates. It is not known whether worries about aphasia offset the benefit in reducing virus transmission, and if so, at what age.

In an effort to answer these questions, researchers conducted a series of studies that tried different masking habits and examined what happened to children in daycare and schools. If one considers these studies unethical, it is not for two simple reasons. First: WHO and CDC disagree on their recommendations. When the major international associations disagree, the equipment survives. Second: Better research as alternatives. In general, it is more ethical to study interventions than to deploy them in tens of thousands of people without knowing if they will help.

Despite the research, the answer is still inconclusive because none of the studies are prospective experiments that measure clinical outcomes. I consider the failure to answer this question one of the greatest failures of the pandemic.

Some might argue that we already have the answers, citing retrospective observational studies. For example, this study suggests that mask requirements for students in K-12 schools are associated with lower transmission (Figure S1 panel I in the study). In contrast, this study by economist Emily Oster, PhD, and colleagues found that students wearing masks in schools had no effect on spreading the virus (masked teachers did). That finding is confirmed by this CDC study (see Table 1).

However, it is the critics who have released fervent criticism of CO .2 Research has been silent. These studies cannot prove anything.

The mask has become a political symbol associated with identity and tribe. The types of schools that do not or do not enforce mask-wearing mandates have very different families and staff and have very different ideas about COVID-19 than the types of schools that enforce mask regulations. religion. The problem of unmeasurable interference is still very much present.

Worse still, everyone – including the researchers – had strong beliefs about whether masks would help. Furthermore, there are tens of thousands of datasets to probe. You can look at schools in Florida, or Georgia, Georgia and Florida, or France, or any combination. When you combine tens of thousands of data sets with hundreds of researchers looking at the question, the flexibility of analysis and the selective reporting results mean that the resulting document is no more than an opinion poll. ants.

Others may argue that mechanical science is sufficient to answer the question. By knowing the size of the virus and the mask’s properties, we can figure out whether the mask will provide a net benefit to children. These people were unfortunately mistaken. Mechanical science cannot answer questions of this scale and scope. If mechanistic science flourishes, all the drugs in development will succeed. Most are not. If mechanistic science were enough, we wouldn’t run randomized trials of complex behavioral interventions (such as MERIT, STAR-ICU, and PRISM).

Large empirical studies alone can answer this question, and we haven’t really been able to do any of it.

So the latest JAMA Department of Pediatrics Research does not prove masks are harmful to children, and those who claim to have debunked the study did not prove masks benefit children or anyone else. Major scientific bodies, funding agencies, public health authorities and researchers have abandoned the hard work of running experiments to reduce uncertainty and hopefully answer questions. Instead, we perform selectively reported, confusingly, retrospective studies of a politically divided population with stereotypes that will forever lead to conclusions. Opposition.

A thousand years from now, to this question, our society will look as crude and ignorant as those who survived the plagues of medieval Europe. The only difference is that we could have done better, and that’s the real point of recent mask research.

Vinay Prasad, MD, MPH, is a hematologist-oncologist and associate professor of medicine at the University of California San Francisco, and the author of Malignancy: How bad policy and bad evidence harm people with cancer.

Disclosure

Prasad has relationships with Arnold Ventures, UnitedHealthcare, eviCore and New Century Health.

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